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Medical Coverage Criteria

Policy NameDownload (PDF)
Abdominoplasty-PanniculectomyDownload (PDF)
Autologous Chondrocyte ImplantationDownload (PDF)
Automatic External DefibrillatorsDownload (PDF)
Balloon SinuplastyDownload (PDF)
Bariatric SurgeryDownload (PDF)
Biomagnetic TherapyDownload (PDF)
BlepharoplastyDownload (PDF)
Breast Implants and ReconstructionDownload (PDF)
Breast Reduction MammoplastyDownload (PDF)
Cardiac Event MonitoringDownload (PDF)
Chemical PeelsDownload (PDF)
Clinical TrialDownload (PDF)
Cochlear and Other Auditory ImplantsDownload (PDF)
Continuous Passive Motion DevicesDownload (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®)Download (PDF)
Cosmetic and Reconstructive Surgery ProceduresDownload (PDF)
DermabrasionDownload (PDF)
Experimental Investigational or Unproved Services PolicyDownload (PDF)
Fecal Incontinence TreatmentDownload (PDF)
Fetal SurgeryDownload (PDF)
Gastric Electrical StimulationDownload (PDF)
Gender Affirming SurgeryDownload (PDF)
Glaucoma SurgeryDownload (PDF)
High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive VentilatorsDownload (PDF)
Home Birth Midwifery ServicesDownload (PDF)
Home Care ServicesDownload (PDF)
Hyperbaric Oxygen TherapyDownload (PDF)
Implantable Cardioverter DefibrillatorsDownload (PDF)
InfertilityDownload (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring SystemsDownload (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.