Medical Necessity Criteria and Clinical Review Guidelines

Care Management uses nationally recognized and accepted utilization management criteria, as well as internally developed policies, guidelines and protocols for medical necessity determination. All criteria are annually reviewed and updated as necessary.

Simply access the criteria that match the service type that you will be providing by choosing the appropriate link, located below. Please contact the Care Management telephone number on the back of the member's identification card should you have any questions.

Criteria Type

MCG Guidelines


  • For Imaging: Select Cardiology and Radiology
  • For Therapy: Select Muskuloskeletal