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

Medical Drug Formulary

• Medical Drug Formulary List
• Medical Drug Site of Care Policy

Supporting Websites

CommunityCare has a partnership with Evolent to administer utilization management for Radiation and Medical Oncology for our Medicare Advantage and Commercial plans.

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)
  • Expanded Cardiac Guidelines

• Advanced Imaging

  • MRI/MRA
  • CT/CTA/CCTA
  • PET
  • Site of Care
  • Advanced Imaging Guidelines

• Physical Medicine Management Services

  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Physical Medicine Clinical Guidelines

• Interventional Pain Management

  • Facet Joint Injections
  • Epidural Spinal Injections
  • Sacroiliac Joint Injections
  • Facet Neurolysis
  • Interventional Pain Management Guidelines

• Musculoskeletal Management Services

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