MEDICAL NECESSITY INSTRUCTIONS FOR USE

Medical Necessity Guidelines outline the factors CareAllies considers in determining medical necessity for a given indication. Please note, the terms of a participant’s particular benefit plan document or summary plan description (SPD) may differ significantly from the standard upon which Medical Necessity Guideline are based. For example, a participant’s benefit plan document or SPD may contain a specific exclusion related to a topic addressed. In the event of a conflict, a participant’s benefit plan document or SPD always supersedes the information in a Medical Necessity Guideline. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document or SPD.

Coverage determinations in each specific instance require consideration of:

1) the terms of the applicable group benefit plan document or SPD in effect on the date of service;

2) any applicable laws/regulations, and;

3) the specific facts of the particular situation. Medical Necessity Guidelines are not recommendations for treatment and should never be used as treatment guidelines.

Medical technology is continuously evolving; our Guidelines are subject to change without prior notice and additional Guidelines may be developed as needed or may be withdrawn from use.  Some benefit plans administered by CareAllies, such as certain self-funded employer plans or governmental plans, may not utilize CAMNGs. Providers and members should contact their Claims Payer for specific coverage information.

At this time, the CAMNGs available at this site represent a portion of the support policies and collateral tools used by CareAllies. We plan to make additional Guidelines available in the future.

CareAllies also uses other tools developed by third-parties to assist in interpreting health benefit plan provisions including Milliman Care Guidelines, a division of Milliman, Inc.

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