Coverage policies are tools to assist in interpreting standard health coverage plan provisions.

Coverage is based on:

• Medicare national coverage determinations (NCDs)
• Local coverage determinations (LCDs)
• The member’s applicable Medicare Evidence of Coverage (EOC) and Summary of Benefits (SOB)

In the absence of an applicable national coverage determination, local coverage determinations, or other CMS-published guidance, MyAdvocate Medicare Advantage uses medical policies based on credible scientific evidence published in peer-reviewed medical literature. These coverage summaries apply to MyAdvocate Medicare Advantage plans.

MyAdvocate Medicare Advantage uses vendor guidelines for certain products to support utilization management review of certain services.

• Acute Inpatient Rehab Facility
• All-cause Readmission Payment Policy Review for Circumvention of Prospective Payment System
• Ambulance Land and Air Transportation
• Experimental of Investigational
• Gender-Affirming Medical and Surgical Procedures
• Home Health Care – Medicare Advantage
• Infuse Bone Graft Bmp-2 Procedure
• Knee Arthroscopy Surgery
• Medicare Advantage Skilled Nursing Facility Coverage Criteria
• Obesity Management Surgical Approaches
• Oral Appliances for the Treatment of Obstructive Sleep Apnea
• Skin and Tissue Substitutes
• Swing Bed
• TMJ Benefit Review
• Total Disc Arthroplasty
• Total Hip Replacement Surgery
• Total Knee Replacement Surgery
• Urinary Incontinence
• Wearable Hearing Aids

The InterQual® Transparency Tool can be used as part of the utilization management process to provide enhanced clinical detail during the review process. This tool allows for consideration of an individual's severity of illness, comorbidities and complications during the review process in real-time. To learn more visit Change Healthcare and follow these steps:

1. Create a One Healthcare ID.
2. Once logged in, you can select the subsets from the drop-down menu.
3. Under product, select the appropriate subsets: LOC: Acute Pediatric, CP: Imaging, etc.