Medicare

Medicare medical policies apply to Medicare Advantage plans in all states and the MyCare Ohio (Medicare-Medicaid) plan.

Medical Policies

Medical policies offer guidance on determination of medical necessity and appropriateness of care for approved benefits. Benefit determinations and coverage decisions are subject to all the terms and conditions of CareSource including eligibility, definitions, specific inclusions or exclusions, and applicable state or federal laws.

The medical policies do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. CareSource is not responsible for, does not provide, and does not represent itself as a provider of medical care.

Policies are considered guidelines and are not intended to infer benefits or coverage for a specific member. Benefit determinations are based on the specific facts of each member’s case. If a service or supply is not eligible for coverage, a member and the treating provider may proceed with that service or supply after receiving a denial from CareSource for the requested non-covered service.

Existing clinical policies are regularly reviewed and updated. New policies are added as appropriate while previous versions are maintained in the policy archive. These policy changes are maintained on this site.

Policy Hierarchy

Decision making for Medicare Advantage is based upon the following hierarchy.

Policy

NCDs and LCDs can be found at www.CMS.gov. Please refer to the Coverage Determinations for Medicare Advantage policy for additional information on this process. The clinical rationale used by CareSource for making health coverage determinations is available by calling or faxing the CareSource Medical Management Department. 

CareSource does not require prior authorization for Part B covered medications. 

Please refer to www.CMS.gov for the guidelines.

Please refer to Medicare Part B/D Coverage Issues.

The policies below are in PDF format. If you do not have Adobe Acrobat Reader, you may download it here.

Current Medical Policies

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Archived Medical Policies