Clinical Criteria

Clinical criteria are used to guide medical decisions regarding diagnosis, management and treatment in health care.

CommunityCare utilizes coverage criteria based on current evidence in widely used treatment guidelines or clinical literature.
InterQual® Transparency  [opens in a new window]

Supporting websites:
CommunityCare may use the following guidelines to support coverage determinations:
Clinical Reference Guidelines

CommunityCare has a partnership with Evolent to administer utilization management for Radiation and Medical Oncology for our Medicare Advantage and Commercial plans. Evolent’s coverage policies can be accessed below.
Evolent Policies

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)

• Advanced Imaging

  • MRI/MRA
  • CT/CTA/CCTA
  • Pet

• Physical Medicine Management Services

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy

• Interventional Pain Management

  • Facet Joint Injections
  • Epidural Spinal Injections
  • Sacroiliac Joint Injections
  • Facet Neurolysis

• Musculoskeletal Management Services

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

Evolent’s coverage policies can be accessed below.

• Advanced Imaging Guidelines  [opens in a new window]
• Expanded Cardiac Guidelines  [opens in a new window]
• Interventional Pain Management Guidelines  [opens in a new window]
• Musculoskeletal Surgery Guidelines  [opens in a new window]
• Physical Medicine Clinical Guidelines  [opens in a new window]