Clinical Criteria

Clinical criteria are used to support consistent, evidence-based decisions regarding the diagnosis, management, and treatment of health care conditions.

CommunityCare uses its plan Medical Policies when an applicable policy is available. When a CommunityCare Medical Policy is not available, CommunityCare uses nationally recognized clinical criteria based on current medical evidence, widely accepted clinical practice guidelines, and relevant clinical literature.

CommunityCare currently uses InterQual® criteria and anticipates transitioning to MCG™ care guidelines on or after August 1, 2026.

InterQual® Transparency

Medical Policies

• CommunityCare Medical Policiescoming soon
• Medical Drug Formulary List
• Medical Drug Site of Care Policy

Supporting Websites

CommunityCare has a partnership with Evolent to administer utilization management for Radiation and Medical Oncology for our Medicare Advantage and Commercial plans.

CommunityCare has a partnership with Evolent to administer utilization management for the following services for our Medicare Advantage and Commercial (employer groups and individual/family plans):

• Diagnostic Cardiology

  • Myocardial Perfusion Imaging (MPI)
  • Mutligated Acquisition Scan (MUGA)
  • Stress Echocardiography
  • Transthoracic Echocardiography (TTE)
  • Transesophageal Echocardiography (TEE)
  • Expanded Cardiac Guidelines

• Advanced Imaging

  • MRI/MRA
  • CT/CTA/CCTA
  • PET
  • Site of Care
  • Advanced Imaging Guidelines

• Physical Medicine Management Services

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Physical Medicine Clinical Guidelines

• Interventional Pain Management

  • Facet Joint Injections
  • Epidural Spinal Injections
  • Sacroiliac Joint Injections
  • Facet Neurolysis
  • Interventional Pain Management Guidelines

• Musculoskeletal Management Services

  • Musculoskeletal Surgery - Lumbar Spine (Fusion and Non-fusion)
  • Musculoskeletal Surgery - Cervical Spine (Fusion and Non-fusion)
  • Musculoskeletal Surgery - Hip, Knee, & Shoulder
  • Musculoskeletal Surgery Guidelines