Clinical Information to Establish Medical Necessity

This eviCore guideline doesn't cover specific procedures but requires legible, sufficiently detailed medical records to establish medical necessity for any test or treatment review — requests with unreadable or insufficient documentation cannot be approved. Key requirements include submission of a recent clinical evaluation with history and physical, relevant labs, imaging, pathology and procedure reports, and reports from other treating providers (the listed elements are examples and additional documentation may be requested).

"Applies to requests for a test or treatment being reviewed by eviCore where medical necessity must be established (no specific procedures, tests, or diagnoses are listed in this document)."

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