EviCore Post-Acute Care and Home Health Care Clinical Guidelines for Medical Necessity

Covers prior authorization determinations for post‑acute care and home health services using the Medicare Benefit Policy Manual (Medicare members only), MCG evidence‑based guidelines, EviCore Home Health Supplementary guidance and other evidence‑based tools for common symptom complexes, while atypical clinical presentations and imaging requests not addressed by the Clinical Decision Support Tool are excluded from automated approval and require physician review. Key requirements: obtain prior authorization aligned with the cited guidelines (Medicare rules apply only to Medicare members), expect physician consultation for atypical cases, and note the policy is proprietary and does not specify explicit documentation checklists or frequency limits.

"Prior authorization criteria for Post-Acute Care services (document header: "Post-Acute Care Prior Authorization Criteria includes, but not limited to:")"