Medical policies translate benefit design, coverage requirements, evidence, and plan-specific rules into reviewable clinical conditions. Physician review identifies the policy that actually governs the member and requested service, then applies it to the complete medical record.
The same service may be reviewed differently depending on the member's product and controlling coverage requirements. A defensible determination begins by identifying the correct benefit and policy framework before applying clinical criteria.
Plan-specific coverage requirements may define covered indications, prerequisites, exclusions, documentation requirements, and other conditions for a requested service.
MA organizations must follow applicable Medicare coverage criteria and may use internal coverage criteria only within the limits permitted by CMS when Medicare coverage criteria are not fully established.
Coverage may depend on the applicable state Medicaid program, managed-care contract, benefit, and plan policy.
Delegated organizations may perform utilization review within contracted responsibilities while remaining subject to the applicable benefit, payer requirements, delegation terms, and governing law.
Licensed decision-support criteria, specialty guidance, and published evidence may inform medical-necessity analysis when authorized and relevant, but the reviewer must first identify the benefit and coverage rules governing the request.
For Medicare Advantage, CMS requires plans to follow Traditional Medicare coverage criteria in applicable statutes, regulations, NCDs, and LCDs. When Medicare coverage criteria are not fully established, CMS permits the use of publicly accessible internal coverage criteria under specified conditions and evidence standards.
Determine whether a statute, regulation, NCD, LCD, or other applicable Traditional Medicare coverage criterion addresses the service.
Determine whether Medicare criteria are fully established for the specific coverage question or whether additional permitted criteria may be needed.
When permitted, confirm that internal criteria are current, publicly accessible, evidence-based, and used within CMS requirements.
Match the governing requirements to the submitted clinical record and explain the material facts supporting the determination.
Policy application is disciplined: identify the member and service, locate the governing policy, verify the policy version, and connect each material requirement to the medical record.
Identify payer, line of business, member product, requested service, and relevant benefit.
Locate the current applicable Medicare, Medicaid, health-plan, or delegated coverage policy.
Check effective date, jurisdiction, product applicability, definitions, prerequisites, and exclusions.
Assess diagnosis, severity, prior treatment, diagnostic findings, contraindications, alternatives, and other required facts.
State which requirements are met or not met and identify the material clinical facts driving the determination.
A member is referred for an advanced diagnostic study or specialty therapy. The reviewer first confirms the member's product and governing coverage policy, then evaluates whether required prior testing, treatment failure, clinical findings, contraindications, or other policy conditions are documented.
If the request involves Medicare Advantage, the reviewer additionally determines whether Traditional Medicare coverage criteria govern the service and whether any plan-specific criteria are permissible for the unresolved coverage question.
Use the current policy version applicable to the member, product, date of service, and jurisdiction. For Medicare Advantage, verify current CMS coverage and utilization-management requirements rather than relying on a commercial-policy framework.
Discuss ongoing coverage, overflow reviews, appeals, or a customized UM program.
Policy requirements structure the review. They do not replace patient-specific physician judgment.
Confirm the applicable benefit, product, delegated arrangement, and review context.
Determine the controlling benefit terms, Medicare authority when relevant, payer policy, and delegated requirements.
Use the policy applicable to the date of service or determination under review rather than automatically applying the current version.
Confirm that diagnosis, service, indication, setting, benefit, and policy scope match the question under review.
Evaluate whether the submitted clinical documentation supports each material requirement.
Explain which requirements are met or not met and identify the patient-specific clinical facts driving the conclusion.
