Clinical Criteria Used for Medical Necessity Decisions

ProCare MSO administers utilization management for its affiliated IPAs, including Premier Patient Care IPA (PPCIPA). The clinical criteria used to make medical necessity determinations, the summary of evidence considered, and the rationale for adoption are publicly available at no cost and without login at https://mso.procareprovider.com/clinical-criteria

Where Traditional Medicare coverage criteria are fully established, determinations follow the applicable National Coverage Determination (NCD), the Local Coverage Determination (LCD) for the service area, and the Medicare Internet-Only Manuals, each linked on this page. Where Traditional Medicare coverage criteria are not fully established, PPCIPA applies publicly posted internal coverage criteria based on current, widely used treatment guidelines and clinical literature, as described on this page.

A copy of the specific criteria used in a determination is also provided with each authorization determination and is available on request at support@procaremso.com or 657-206-8700.

Type any part of a condition, procedure, or policy number to filter every set on this page.

National Medicare coverage policy. Published by the Centers for Medicare & Medicaid Services and reproduced here in full. Each document below opens directly as a PDF. No account and no sign-in are required.

Local Medicare coverage policy for the California service area, published by the Medicare Administrative Contractor and reproduced here in full. Each document below opens directly as a PDF. No account and no sign-in are required.

Inpatient guideline sets adopted for medical necessity review where Traditional Medicare coverage criteria are not fully established. Each document below opens directly as a PDF. No account and no sign-in are required.

Outpatient and ambulatory guideline sets adopted for medical necessity review where Traditional Medicare coverage criteria are not fully established. Each document below opens directly as a PDF. No account and no sign-in are required.

National and Local Coverage Determinations are published by the Centers for Medicare & Medicaid Services and its Medicare Administrative Contractors. Current versions are searchable in the CMS Medicare Coverage Database, and the Internet-Only Manuals are published in the CMS Internet-Only Manuals.

MCG guidelines are developed and licensed by MCG Health. Requests for the criteria applied to a specific determination, or for the summary of evidence and rationale supporting adoption of a criterion, are furnished at no cost at support@procaremso.com or 657-206-8700.

Utilization management decisions are based only on the appropriateness of care and service. ProCare MSO does not compensate or reward practitioners or reviewers for denials of coverage.