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Medical necessity criteria


We base on our medical necessity criteria on several sources:

  • MCG(r) Moda Health utilizes the evidence-based MCG® for:
    • Inpatient and outpatient surgeries
    • Initial and ongoing goal length of stay for admissions to:
      • Inpatient facilities, including medical and behavioral health admissions
      • Skilled nursing facilities
      • Acute in-patient rehabilitation
      • Long-term acute care facilities
    • Outpatient therapies
    • Durable medical equipment
  • eviCore- for Advanced Imaging, Cardiology and Musculoskeletal procedures and services

Complete list of our Medical Necessity Criteria Procedures (for Commercial Plans)

Questions?

Medical Customer Service is at 844-931-1779.

We're available 6:00 a.m. to 6:00 p.m. Monday through Friday, 9:00 a.m. to Noon Saturday, Sunday, and Holidays (Central Time).

See more contact details

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