Medicare coverage criteria guidelines

Criteria we use in determining medical necessity for coverage.

Providers contracted with Sharp Health Plan are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members.

When coverage criteria are not fully established by Medicare, we use evidence-based guidelines according to our Sharp Health Plan clinical policies and other national and third-party criteria, which are based on generally accepted standards of care described below. These evidence-based guidelines provide clinical benefits that are highly likely to outweigh any clinical harm, including from delayed or decreased access to items or services.

How clinical staff use coverage criteria

Clinical staff use criteria for medical and surgical coverage and for behavioral health coverage as listed in the following section. Criteria are ranked from 1 to 5. This means clinical staff always check the Medicare National Coverage Determinations first, because it’s ranked No. 1. If Medicare does not offer guidance on a medical service, then clinical staff will check the Local Coverage Determinations next, because it’s ranked No. 2, and so on.

The hierarchy of coverage criteria

Medical and surgical coverage criteria and behavioral health coverage criteria are each ranked 1 to 5 in the charts below. Please note that many guidelines are written primarily for health care professionals. Some guidelines include materials written for patients when available.

Medical and surgical coverage criteria
Behavioral health coverage criteria

About Sharp Health Plan clinical policies

Sharp Health Plan develops clinical policies that serve as guidelines for medical necessity determinations, based on medical evidence such as:

  • Guidelines from nationally recognized health care organizations
  • Guidelines published by nationally recognized professional organizations
  • Available protocols regarding use of drug, device, procedure or therapy adopted by academic institutions
  • Peer-reviewed medical and scientific literature
  • Evidence-based consensus statements
All Sharp Health Plan clinical policies are the intellectual property of Sharp Health Plan. No part of our clinical policies may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the Plan.

Who develops the clinical policies for Sharp Health Plan?
Our clinical policies are written by board-certified, California-licensed physicians, then edited and approved by a committee of physicians including primary care and specialists.

How does Sharp Health Plan keep its clinical policies up to date?
Each clinical policy is reviewed and updated yearly. The yearly review includes analysis of new peer-reviewed literature and new professional society guidelines.

How do providers use Sharp Health Plan clinical policies?
Providers use our clinical policies as reference in conjunction with the independent judgment of the treating qualified licensed physician(s).

Sharp Health Plan clinical policies do not constitute the practice of medicine or medical advice. They are not intended to dictate to providers how to practice medicine, and they are not intended to recommend treatment for members. Members should consult with their treating provider in connection with diagnosis and treatment decisions.

Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

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Page Last Updated: 4/01/2024
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