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Medical Coverage Criteria

  1. Home
  2. Home
  3. Our Policies
  4. Medical
  1. Commercial
  2. Medicare

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

Please note, by downloading or viewing any of the criteria below, you have agreed to accept
ConnectiCare's Preauthorization Criteria User Agreement.

 

Services That Require Preauthorization

View EmblemHealth Medical Policies

 

In addition to the medical coverage policies listed below, the following resources are used to make medical necessity determinations.

 
Policy Name Download (PDF)
Abdominoplasty-Panniculectomy Download (PDF)
Ambulance Download (PDF)
Ambulatory Monitoring Electroencephalogram (EEG) Download (PDF)
Arthroscopy-Arthroplasty Download (PDF)
Autologous Chondrocyte Implantation Download (PDF)
Automatic External Defibrillators Download (PDF)
Balloon Sinuplasty Download (PDF)
Bariatric Surgery Download (PDF)
Biomagnetic Therapy Download (PDF)
Blepharoplasty Download (PDF)
Bone Mineral Density Studies in Adult Populations Download (PDF)
Breast Implants and Reconstruction Download (PDF)
Capsule Endoscopy (Camera Pill) Download (PDF)
Cardiac Event Monitoring Download (PDF)
Cartilage Implants Download (PDF)
Chemical Peels Download (PDF)
Clinical Trial Download (PDF)
Cochlear Implants Download (PDF)
Congenital Heart Disease Download (PDF)
Continuous Passive Motion Devices Download (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®) Download (PDF)
Cosmetic and Reconstructive Surgery Procedures Download (PDF)
Craniofacial Procedures Download (PDF)
Cryosurgical Ablation for Prostate Cancer Download (PDF)
Cryosurgical and Radiofrequency Ablation for Renal Tumors Download (PDF)
Deep Brain Stimulation Download (PDF)
Dermabrasion Download (PDF)
Durable Medical Equipment Download (PDF)
Experimental Investigational or Unproved Services Policy Download (PDF)
External Counterpulsation Download (PDF)
Fecal Incontinence Treatment Download (PDF)
Fecal Microbiota Transplant (FMT) for Recurrent Clostridium Difficile Infection Download (PDF)
Formula and Enteral Nutrition-CT Download (PDF)
Formula and Enteral Nutrition-MA Download (PDF)
gammaCore Sapphire CV Coronavirus Download (PDF)
Gastric Electrical Stimulation Download (PDF)
Gender Affirming Reassignment Surgery Download (PDF)
Glaucoma Surgery Download (PDF)
Gynecomastia Download (PDF)
High Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive Ventilators Download (PDF)
Home Health Aide Download (PDF)
Home Care Download (PDF)
Hyperbaric Oxygen Therapy Download (PDF)
Hysterectomy Download (PDF)
Idiopathic Environmental Intolerance Download (PDF)
Infertility Download (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems Download (PDF)
Lipoprotein Subclassification Testing for Screening, Evaluation, and Monitoring of Cardiovascular Disease Download (PDF)
Lyme Disease Diagnosis & Treatment Download (PDF)
Lymphedema Treatment  Download (PDF)
Mechanical Stretching Devices Download (PDF)
Neuropsychological Testing Download (PDF)
Non-Invasive Electroencephalogram (EEG) Download (PDF)
Non-Invasive H-Pylori Testing
Download (PDF)
Non-Invasive Prenatal Testing (NIPT) for Fetal Aneuploidy Download (PDF)
Obstructive Sleep Apnea Diagnosis and Treatment Download (PDF)
Ocular Photoscreening Policy Download (PDF)
Omnibus Policy
Download (PDF)
Oral Surgery Download (PDF)
Orthognathic Surgery Download (PDF)
Osteochondral Grafting
Download (PDF)
Osteogenic Stimulators – Non-Spinal Applications Download (PDF)
Osteogenic Stimulators – Spinal Applications Download (PDF)
Osteogenic Stimulators – Ultrasound, Non-invasive Download (PDF)
Osteopathic Manipulative Treatment Policy Download (PDF)
Otoacoustic Emissions Testing Policy Download (PDF)
Penile Implants Download (PDF)
Peripheral Nerve Block Download (PDF)
Periurethral Bulking Agents for Urinary Incontinence Download (PDF)
Phototherapy Photochemotherapy Photodynamic Therapy Download (PDF)
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Download (PDF)
Power Mobility Device Download (PDF)
Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions Download (PDF)
Radiofrequency Ablation for Spinal Pain Download (PDF)
Radiofrequency Ablation for Tumors Download (PDF)
Reduction Mammoplasty Download (PDF)
Rhinoplasty Download (PDF)
Septoplasty Download (PDF)
Site of Service Policy Download (PDF)
Stimulators (Neurostimulation) Download (PDF)
Surgical Correction Chest Wall Deformities Download (PDF)
Sympathectomy for Hyperhidrosis Download (PDF)
Tonsillectomy-Adenoidectomy Download (PDF)
Transcatheter Aortic Valve Replacement Download (PDF)
Vacuum-Assisted Wound Closure Download (PDF)
Varicose Vein Treatment Download (PDF)
Ventricular Assist Device Download (PDF)
Vertical Expandable Prosthetic Titanium Rib (VEPTR) Download (PDF)
Vitamin D Deficiency Testing
Download (PDF)

Milliman Care Guidelines

Providers can view information on ConnectiCare medical criteria at connecticare.access.mcg.com/index.

Providers can view the medical criteria provided by Milliman Care Guidelines (MCG), a national, third-party source that ConnectiCare uses. For accessing these guidelines, sign in to your member account on this website and then this link: Milliman Care Guidelines

 

To access the Milliman Care Guidelines, you should have received a letter from ConnectiCare with the following information you need to enter:

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.    Hit submit and you will be directed to the MCG guideline

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


Please note, by downloading or viewing any of the criteria below, you have agreed to accept
ConnectiCare's Preauthorization Criteria User Agreement.

 

Services That Require Preauthorization

View EmblemHealth Medical Policies

 

 Policy Name Download (PDF)
2020 Prior Authorization Download (PDF)
Acupuncture for Chronic Lower Back Pain Download (PDF)
Ambulance Download (PDF)
Ambulatory ECG Download (PDF)
Ambulatory Monitoring Electroencephalogram (EEG) Download (PDF)
Autologous Chondrocyte Implantation Download (PDF)
Automatic External Defibrillators Download (PDF)
Balloon Sinuplasty Download (PDF)
Biomagnetic Therapy  Download (PDF)
Blepharoplasty
Download (PDF)
Breast Implants and Reconstruction Download (PDF)
Capsule Endoscopy (Camera Pill) Download (PDF)
Chemical Peels Download (PDF)
Clinical Trials Download (PDF)
Continuous Passive Motion Devices Download (PDF)
Cortical Stimulation for Epilepsy (NeuroPace®) Download (PDF)
Cryosurgical Ablation for Prostate Cancer Download (PDF)
Cryosurgical and Radiofrequency Ablation for Renal Tumors Download (PDF)
Dermabrasion Download (PDF)
Experimental, Investigational or Unproven Services Download (PDF)
Fecal Incontinence Treatment Download (PDF)
Fecal Microbiota Transplant (FMT) for Recurrent Clostridium Difficile Infection Download (PDF)
gammaCore Sapphire CV Coronavirus Download (PDF)
Gender Affirming Reassignment Surgery Download (PDF)
High Frequency Chest Wall Oscillation Devices Intrapulmonary Percussive Ventilators Download (PDF)
Hyperbaric Oxygen Therapy Download (PDF)
Insulin Delivery Devices and Continuous Glucose Monitoring Systems Download(PDF)
Lipoprotein Subclassification Testing for Screening, Evaluation, and Monitoring of Cardiovascular Disease Download (PDF)
Lymphedema Treatment 
Download (PDF)
Obstructive SleepApnea Diagnosis and Treatment Download (PDF)
Omnibus Policy Download (PDF)
Osteochondral Grafting
Download (PDF)
Penile Implants Download (PDF)
Peripheral Nerve Blocks Download (PDF)
Periurethral Bulking Agents for Urinary Incontinence
Download (PDF)
Phototherapy Photochemotherapy Photodynamic Therapy Download (PDF)
Posterior Tibial Nerve Stimulation for Voiding Dysfunction Download (PDF)
Pulmonary Rehab Download (PDF)
Radiofrequency Ablation for Spinal Pain Download (PDF)
Site of Service Policy Download (PDF)
Varicose Vein Treatment Download (PDF)

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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.

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