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)

• Abdominoplasty – Panniculectomy
• Acupuncture
• Aflibercept: Eylea®; Eylea® HD
• Air Ambulance Transport
• Allergy Testing – Blood
• Anesthesia for Routine Endoscopic Procedures
• Ankle-Foot Orthoses(AFOs)/Knee-Ankle-Foot Orthoses(KAFOs)/Hip-Knee-Ankle-Foot Orthoses(HKAFOs)
• Anodyne
• Applied Behavior Analysis
• Balloon Dilation of Eustachian Tube
• Blepharoplasty and Brow Ptosis Repair
• Bone Growth Stimulators Electric
• BRACAnalysis CDx (Myriad)
• Breast Implant Removal
• Breast Pumps
• Breast Reconstruction
• Cardiac Defibrillators, external
• Cardiac Disease Screening-Lipid Profile
• Chemical Dependency Inpatient, Residential and Outpatient Treatment
• Chiropractic Services
• Clinical Trials
• Cochlear Implants and Auditory Brainstem Implants
• Computer Assisted Navigation for Musculoskeletal Procedures
• Coordinated Specialty Programs
• Custom compression garments
• Continuous Glucose Monitoring
• Cooling Devices
• Corneal Collagen Cross-linking for Treatment of Keratoconus
• Cranial Orthotics
• Cryoablation of Breast Fibroadenomas
• Disease Management for Pain (Pain Schools)
• DME General Policy
• Eating Disorders
• Electrical Stimulation Devices
• Endoscopic Procedures for the Treatment of GERD
• Experimental and investigational services
• External Infusion Insulin Pumps
• Extracorporeal Shock Wave Therapy (ESWT)
• Factor V Leiden Thrombophilia
• Genetic Testing
• Hearing Assistive Technology
• Herniated Disc - Non-covered Procedures
• High Frequency Chest Wall Oscillation Devices (HFCWO)
• Hospital Beds and Accessories for Home use
• Hyaluronic Acid Derivatives
• Hydrogen Breath Testing
• Hyperbaric Oxygen
• Inpatient Mental Health
• Interferential Stim Devices
• Interspinous Decompression and Interlaminar Devices
• Intervertebral Disc Prosthesis
• Intraocular Lens Implant
• Intraoperative Neurophysiologic Monitoring
• Intrathecal Opioid Therapy
• Kyphoplasty/Vertebroplasty
• Lanreotide: Somatuline® Depot; Lanreotide Ψ
• Long-Term Psychotherapy
• Mechanical Stretching Devices
• Medical Nutrition Therapy/Nutritional Counseling
• Mental Health Partial Hospitalization and Intensive Outpatient Treatment
• Micronutrient Testing
• Mobile Outpatient Cardiac Telemetry (MOCT)
• Negative Pressure Wound Therapy (NPWT) (Vacuum-Assisted Wound Closure)
• Nitric Oxide Therapy - Inhaled
• Non-invasive Testing for Liver Fibrosis
• Obesity, Surgical Management
• Obstructive Sleep Apnea Non-Surgical Treatment
• Obstructive Sleep Apnea Surgical Treatment
• Omvoh® (mirikizumab-mrkz)
• Patient Lifts
• Post-Operative Sinus Endoscopy-Debridement Procedures
• Prolotherapy
• Prostate Cancer Genomic Assay
• Psychiatric Residential Treatment-Children, Adolescents and Adults
• Pulmonary Rehabilitation
• Push rim-activated power-assist device for manual wheelchair
• Reactive Attachment Disorder
• Reduction Mammoplasty
• Salivary Hormone Testing
• Serum Antibodies for IBD
• Sinus Surgery
• Skin and Tissue Substitutes - Engineered
• Spinal Cord Stimulators
• Spinal Pain Injections
• Standers/Standing frames
• Surgical Treatment for Achalasia
• Therapeutic Drug Monitoring
• Thermography
• Temporomandibular Joint (TMJ) Non-Surgical Treatment
• Transcranial Magnetic Stimulation
• Upper Extremity Orthoses
• Upper extremities prostheses (standard/non-myoelectric)(
• Urinary Incontinence
• Virtual Colonoscopy