Clinical Information to Establish Medical Necessity

This policy covers use of eviCore’s Clinical Decision Support Tool and proprietary Clinical Review Criteria to determine medical necessity for prior authorization of post‑acute and home health services for delegated patients, while atypical presentations or cases not addressed by the tool may be excluded or require additional review and the CRC content is restricted from redistribution. Key requirements: provide clinical documentation demonstrating symptoms and medical necessity per eviCore/ referenced resources (e.g., Medicare Benefit Policy Manual, MCG), evidence of delegated‑patient status, and physician review/documentation (plus consult notes) for atypical or unclear presentations.

"Certain referenced resources apply to Medicare members only (e."

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