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Medical Coverage Criteria

Review ConnectiCare's policies on various medical treatments and emerging medical technologies.

For other Medical Policies, see:

* 2026 and 2025 Employer groups and 2025 Marketplace (Individual)

** See instructions for finding specific MCG guidelines shared in determination letters

Policy NameDownload (PDF)
Abdominoplasty-PanniculectomyDownload (PDF)
Actemra tocilizumab and Biosimilars C10265-ADownload (PDF)
Acthar Gel repository corticotropin injection C8373-A2026 Download (PDF)
Adakveo (crizanlizumab-tmca) C17920-A2026 Download (PDF)
Aduhelm (aducanumab-avwa) C21304-A2026 Download (PDF)
Aldurazyme (laronidase) C28302-A2026 Download (PDF)
Adzynma (adamts13, recombinant-krhn) C27325-A2026 Download (PDF)
Alpha-1 Antitrypsin (AAT) Deficiency Enzyme C8797-A2026 Download (PDF)
Amondys 45 (casimersen) NC C21153-A2026 Download (PDF)
Amvuttra (vutrisiran) C24213-A2026 Download (PDF)
Antiemetics C20780-A 2026 Download (PDF)
Aphexda (motixafortide) C27171-A2026 Download (PDF)
Autologous Chondrocyte ImplantationDownload (PDF)
Automatic External DefibrillatorsDownload (PDF)
Balloon SinuplastyDownload (PDF)
Bariatric SurgeryDownload (PDF)
Baxdela (delafloxacin) C16332-A2026 Download (PDF)
Benlysta (belimumab) C2722A2026 Download (PDF)
Biomagnetic TherapyDownload (PDF)
BlepharoplastyDownload (PDF)
Beovu (brolucizumab) C17923-A2026 Download (PDF)
Botulinum Toxin C8755-A2026 Download (PDF)
Breast Implants and ReconstructionDownload (PDF)
Breast Reduction MammoplastyDownload (PDF)
Brineura (cerliponase alfa) C11526-A2026 Download (PDF)
Briumvi (ublituximab) C25204-A2026 Download (PDF)
Brixadi (buprenorphine ER inj) C27170-A2026 Download (PDF)
Cablivi (caplacizumab) Criteria C19481-A2026 Download (PDF)
Calcitonin Gene-Related Peptide (CGRP) antagonist C15443-C2026 Download (PDF)
Cardiac Event MonitoringDownload (PDF)
Chemical PeelsDownload (PDF)
Cinqair (reslizumab) C9761-A2026 Download (PDF)
Clinical TrialDownload (PDF)
Cochlear and Other Auditory ImplantsDownload (PDF)
Constipation Agents C24671-A2026 Download (PDF)
Continuous Passive Motion DevicesDownload (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®)Download (PDF)
Cosela (trilaciclib) C21205-A2026 Download (PDF)
Cosentyx (secukinumab) C10410-A2026 Download (PDF)
Cosmetic and Reconstructive Surgery ProceduresDownload (PDF)
Crysvita (Burosumab-twza) C14517-A2026 Download (PDF)
Cubicin (daptomycin) C10467-A2026 Download (PDF)
Cytogam (cytomegalovirus immune globulin) C9970-A2026 Download (PDF)
DermabrasionDownload (PDF)
Dalvance (dalbavancin) C9351-A2026 Download (PDF)
Dextenza (dexamethasone intracanalicular insert) C24242-A 2026 Download (PDF)
Dexycu (dexamethasone intraocular suspension) C16320-A2026 Download (PDF)
Durysta (bimatoprost implant) C19830-A2026 Download (PDF)
Elaprase (idursulfase) C2720-A2026 Download (PDF)
Elfabrio pegunigalsidase alfa C25604-A2026 Download (PDF)
Enjaymo (sutimlimab) C22996-A2026 Download (PDF)
Entyvio (vedolizumab) C6773-A2026 Download (PDF)
Enzyme Replacement Therapy for Gaucher Disease [Cerezyme, Elelyso, Vpriv] C9674-A2026 Download (PDF)
Erythropoiesis-stimulating Agents (ESAs) C15389-A2026 Download (PDF)
Evenity (romosozumab-aqqg) C17324-A2026 Download (PDF)
Evkeeza (evinacumab_dgnb) C21101-A2026 Download (PDF)
Experimental Investigational or Unproved Services PolicyDownload (PDF)
Exondys 51 (eteplirsen) NC C9941-A2026 Download (PDF)
Eylea (aflibercept) and Biosimilars C5674-A2026 Download (PDF)
Fabrazyme (agalsidase beta) C4865-A2026 Download (PDF)
Fasenra (benralizumab) C13643-A 2026 Download (PDF)
Fecal Incontinence TreatmentDownload (PDF)
Fetal SurgeryDownload (PDF)
Gamifant (emapalumab-lzsg) C15970-A2026 Download (PDF)
Gastric Electrical StimulationDownload (PDF)
Gender Affirming SurgeryDownload (PDF)
Gender Dysphoria Hormone Therapy C17908-A2026 Download (PDF)
Glaucoma SurgeryDownload (PDF)
Givlaari (givosiran) C17924-A2026 Download (PDF)
Granulocyte Colony-Stimulating Factors C29652-A2026 Download (PDF)
Hemophilia and Blood Factor Products C15607-A2026 Download (PDF)
Hepatitis B Immune Globulin C9971-A2026 Download (PDF)
Hereditary Angioedema Agents C21463-A2026 Download (PDF)
High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive VentilatorsDownload (PDF)
Home Birth Midwifery ServicesDownload (PDF)
Home Care ServicesDownload (PDF)
Hyaluronic Acid (HA) Injections_Viscosupplementation for Knee OsteoArthritis C14676-A2026 Download (PDF)
Hyperbaric Oxygen TherapyDownload (PDF)
iDose TR (travoprost intracameral implant) C27707-A2026 Download (PDF)
Ilaris (canakinumab) C2435-A2026 Download (PDF)
Ilumya (tildrakizumab) C15971-A2026 Download (PDF)
Iluvien (fluocinolone acetonide intravitreal implant) C11728-A2026 Download (PDF)
Imaavy (nipocalimab-aahu) C29627-A2026 Download (PDF)
Imcivree (setmelanotide) NC C22214-A2026 Download (PDF)
Immunoglobulin (SCIg, IVIg) C21554-A2026 Download (PDF)
Implantable Cardioverter DefibrillatorsDownload (PDF)
InfertilityDownload (PDF)
Infliximab (Remicade_Renflexis_Ixifi_Avsola_Inflectra) C10421-A2026 Download (PDF)
InPen (Smart Insulin Pen) C29696-A2026 Download (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring SystemsDownload (PDF)
Intravenous Bisphosphonates C16790-A2026 Download (PDF)
Iron Deficiency Anemia Agents C14569-A2026 Download (PDF)
Iron Chelating Agents (Desferal Exjade Ferriprox Jadenu) C15214-A2026 Download (PDF)
Izervay avacincaptad intravitreal C26436-A2026 Download (PDF)
Kanuma (sebelipase alfa) C9974-A2026 Download (PDF)
Kisunla (donanemab-azbt) C28657-A2026 Download (PDF)
Krystexxa (pegloticase) C2729-A2026 Download (PDF)
Lamzede (velmanase alfa) C25436-A2026 Download (PDF)
Lemtrada (alemtuzumab) C6919-A2026 Download (PDF)
Leqembi (lecanemab) C25201-A2026 Download (PDF)
Lyme Disease Intravenous TreatmentDownload (PDF)
Mechanical Stretching DevicesDownload (PDF)
Neuropsychological TestingDownload (PDF)
Non-Emergent Ambulance ServicesDownload (PDF)
Obstructive Sleep Apnea Diagnosis and TreatmentDownload (PDF)
Ocular Photoscreening PolicyDownload (PDF)
Omnibus PolicyDownload (PDF)
Oral SurgeryDownload (PDF)
Orthognathic SurgeryDownload (PDF)
Osteochondral GraftingDownload (PDF)
Otoacoustic Emissions Testing PolicyDownload (PDF)
Penile ImplantsDownload (PDF)
Peripheral Nerve BlockDownload (PDF)
Phototherapy Photochemotherapy Photodynamic TherapyDownload (PDF)
Posterior Tibial Nerve Stimulation for Voiding DysfunctionDownload (PDF)
Pulsed Dye Laser Therapy for Cutaneous Vascular LesionsDownload (PDF)
Radiofrequency Ablation for Spinal PainDownload (PDF)
Radiofrequency Ablation for TumorsDownload (PDF)
Reduction MammoplastyDownload (PDF)
RhinoplastyDownload (PDF)
SeptoplastyDownload (PDF)
Surgical Correction Chest Wall DeformitiesDownload (PDF)
Transcatheter Aortic Valve ReplacementDownload (PDF)
Vacuum-Assisted Wound ClosureDownload (PDF)
Varicose Vein TreatmentDownload (PDF)
Vertical Expandable Prosthetic Titanium Rib (VEPTR)Download (PDF)

Finding Specific MCG Clinical Guidelines Shared In Determination Letters

ConnectiCare sends determination letters to members with copies to their providers with a code to the specific MCG medical criteria used during the clinical review.  

Letters instruct the reader to go to the webpage connecticare.access.mcg.com and to have the following information ready to enter on the screen:

  1. The date at the top of your letter.
  2. Your last name as is listed in your letter.
  3. The guideline code listed at the beginning of your letter.
  4. The password listed at the beginning of your letter.
  5. Click submit to be directed to the MCG guideline.
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Any information provided on this website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.