Clinical Practice Guidelines and Medical Necessity

Clinical Practice Guidelines

The following clinical practice guidelines are intended to support our health care team and serve as resources to ensure our providers have the most up to date, evidence-based information recommended by nationally recognized organizations. AMDA – The Society for Post-Acute and Long-Term Care Medicine  – This is the standard care process in the post-acute and long-term care (PA/LTC) setting.

    Guidelines are provided for informational purposes only and are not meant to direct individual treatment decisions. All patient care and related decisions are the sole responsibility of providers. These guidelines do not dictate or control a provider’s clinical judgement regarding the appropriate treatment of a patient in any given case.

    Medical Necessity

    “Medically Necessary” or “Medical Necessity” means health care services or supplies that a physician, exercising prudent judgement, would provide and/or order for a patient. The services must be:

    1. a) in accordance with generally accepted standards of medical practice;
    2. b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
    3. c) not primarily for the convenience of the patient, physician, or other health care provider, and
    4. d) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease

    Simpra Advantage utilizes the following Medical Necessity criteria to guide utilization management decisions. This may include, but is not limited to, decisions involving inpatient reviews, prior authorizations, level of care, and retrospective reviews.

    1. Centers for Medicare and Medicaid (CMS) Criteria
    2. Milliman Care Guidelines (MGC)

    Simpra Advantage Medical Necessity criteria does not supersede state or Federal law or regulation.