Medicare coverage criteria guidelines

Criteria we use in determining medical necessity for coverage.

Providers contracted with Sharp Health Plan are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members.

When coverage criteria are not fully established by Medicare, we use evidence-based guidelines according to our Sharp Health Plan clinical policies and other national and third-party criteria, which are based on generally accepted standards of care described below. These evidence-based guidelines provide clinical benefits that are highly likely to outweigh any clinical harm, including from delayed or decreased access to items or services.

How clinical staff use coverage criteria

Clinical staff use criteria for medical and surgical coverage and for behavioral health coverage as listed in the following section. Criteria are ranked from 1 to 5. This means clinical staff always check the Medicare National Coverage Determinations first, because it’s ranked No. 1. If Medicare does not offer guidance on a medical service, then clinical staff will check the Local Coverage Determinations next, because it’s ranked No. 2, and so on.

The hierarchy of coverage criteria

Medical and surgical coverage criteria and behavioral health coverage criteria are each ranked 1 to 5 in the charts below. Please note that many guidelines are written primarily for health care professionals. Some guidelines include materials written for patients when available.

Medical and surgical coverage criteria

	Evidence-based guidelines	How to access guidelines
1	Medicare National Coverage Determinations	Search the Medicare Coverage Database Or, see PDFs of the Medicare National Coverage Determinations Manual
2	Local Coverage Determinations for durable medical equipment (DME) only if no National Coverage Determinations	Search the Medicare Coverage Database Or, search Local Coverage Determinations through Noridian Medicare
3	Medicare-specific Sharp Health Plan clinical policies	View bone mass policy (PDF) View hearing aid policy (PDF) View injectable medications policy (PDF) View second opinion policy (PDF) View telehealth policy (PDF)
4	National Comprehensive Cancer Network (NCCN) Guidelines for oncology	Browse NCCN guidelines by cancer type
	MCG Care Guidelines for ambulatory care, inpatient and surgical care, and recovery facility care	MCG Care Guidelines are proprietary to MCG. This means MCG guidelines are password-protected, and only one guideline can be viewed at a time. Here’s what to do: Call Sharp Health Plan Customer Care at 1‑855‑562‑8853 (TTY/TDD 711). Give the representative the Guideline Code, or tell the representative you’re interested in the MCG Care Guidelines that Sharp Health Plan uses to determine medical necessity. You can only view one guideline at a time, so be specific with your interest: Ambulatory care guidelines support outpatient authorization of genetic medicine, procedures and diagnostic tests, injectable and high-cost medications, imaging, rehabilitation evaluations, therapies, and services, subspecialty referrals, and durable medical equipment (DME). Inpatient and surgical care guidelines include hundreds of condition-specific guidelines. Recovery facility care guidelines focus on admission and discharge decisions with skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs), as well as required treatments or therapies. If an MCG Care Guideline is available for your interest, Customer Care will provide you with a password to access the MCG website. After you get the Guideline Code and password, go to the MCG website. Enter the date, your last name, Guideline Code and password.
	CVS Clinical Criteria for medications	Search CVS clinical criteria
	U.S. Food & Drug Administration for FDA-approved drugs	Search Drugs@FDA online database
5	Other guidelines and tools developed by third parties to assist in determining medical necessity and administering health beneﬁts, i.e., professional associations	Third-party guidelines and tools vary based on the service (e.g., procedure, treatment, equipment) being reviewed. See About Sharp Health Plan clinical policies for details on how relevant medical evidence is sourced.

Behavioral health coverage criteria

	Evidence-based guidelines	How to access guidelines
1	Medicare National Coverage Determinations	Search the Medicare Coverage Database Or, see PDFs of the Medicare National Coverage Determinations Manual
2	Local Coverage Determinations for durable medical equipment (DME) only if no National Coverage Determinations	Search the Medicare Coverage Database Or, search Local Coverage Determinations through Noridian Medicare
3	Medicare-specific Sharp Health Plan clinical policies	View injectable medications policy (PDF) View second opinion policy (PDF) View telehealth policy (PDF)
4	Magellan Healthcare Clinical Guidelines	Browse Magellan Healthcare’s clinical guidelines
	MCG Care Guidelines for behavioral health	MCG Care Guidelines are proprietary to MCG. This means MCG guidelines are password-protected, and only one guideline can be viewed at a time. Here’s what to do: Call Sharp Health Plan Customer Care at 1‑855‑562‑8853 (TTY/TDD 711). Give the representative the Guideline Code, or tell the representative you’re interested in the MCG Care Guidelines that Sharp Health Plan uses to determine medical necessity. You can only view one guideline at a time, so be specific with your interest: Behavioral health care guidelines include guidance for multiple diagnostic groups to help determine the appropriate level of care. If an MCG Care Guideline is available for your interest, Customer Care will provide you with a password to access the MCG website. After you get the Guideline Code and password, go to the MCG website. Enter the date, your last name, Guideline Code and password.
	ASAM Criteria^® for addiction and co-occurring conditions	Review ASAM Criteria dimensions
	CVS Clinical Criteria for medications	Search CVS clinical criteria
	U.S. Food & Drug Administration for FDA-approved drugs	Search Drugs@FDA online database
5	Other guidelines and tools developed by third parties to assist in determining medical necessity and administering health beneﬁts, i.e., professional associations	Third-party guidelines and tools vary based on the service (e.g., procedure, treatment, equipment) being reviewed. See About Sharp Health Plan clinical policies for details on how relevant medical evidence is sourced.

About Sharp Health Plan clinical policies

Sharp Health Plan develops clinical policies that serve as guidelines for medical necessity determinations, based on medical evidence such as:

Guidelines from nationally recognized health care organizations
Guidelines published by nationally recognized professional organizations
Available protocols regarding use of drug, device, procedure or therapy adopted by academic institutions
Peer-reviewed medical and scientific literature
Evidence-based consensus statements

All Sharp Health Plan clinical policies are the intellectual property of Sharp Health Plan. No part of our clinical policies may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the Plan.

Who develops the clinical policies for Sharp Health Plan?
Our clinical policies are written by board-certiﬁed, California-licensed physicians, then edited and approved by a committee of physicians including primary care and specialists.

How does Sharp Health Plan keep its clinical policies up to date?
Each clinical policy is reviewed and updated yearly. The yearly review includes analysis of new peer-reviewed literature and new professional society guidelines.

How do providers use Sharp Health Plan clinical policies?
Providers use our clinical policies as reference in conjunction with the independent judgment of the treating qualiﬁed licensed physician(s).

Sharp Health Plan clinical policies do not constitute the practice of medicine or medical advice. They are not intended to dictate to providers how to practice medicine, and they are not intended to recommend treatment for members. Members should consult with their treating provider in connection with diagnosis and treatment decisions.

Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

H5386_2025_Medicare Website_Rev 2

Page Last Updated: 4/01/2024