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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 for Medications and Procedures (for Commercial Plans)

Questions?

See a full list of contact details including provider relations and customer service.

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