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Magellan Health

Medical Necessity Criteria

Medical Necessity Criteria -- 2016 (effective January 1, 2016) (PDF)

Medical Necessity Criteria -- 2015 (effective January 1, 2015) (PDF)

Medical Necessity Criteria -- 2014 (effective January 1, 2014) (PDF)


State-Specific and Client Requirements

Specific state laws and client requirements may require modified medical necessity criteria. If you have members in care under any of the benefit plans, in any of the states, or employed by any of the employers requiring modified criteria, please refer to the appropriate medical necessity criteria below. For more information on the use of the below criteria, please contact the medical director at your Magellan Care Management Center.

American Society of Addiction Medicine (ASAM) – substance abuse criteria for:

  • Independence Blue Cross and its affiliates' covered members in Pennsylvania, New Jersey, and Delaware
  • Capital Blue Cross covered members
  • Pennsylvania HealthChoices' child and adolescent members
  • Other customers throughout the country

Applied Behavior Analysis Medical Necessity Criteria

Blue Shield of California – information on medical necessity criteria for providers serving Blue Shield of California members can be found in the California Medical Necessity Criteria with the exception of specific Neuropsych Testing Medical Necessity Guidelines.

California Medical Necessity Criteria – medical necessity criteria for providers serving members in California.

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) Medical Necessity Criteria (PDF) – criteria to guide providers to the most appropriate level of care for CHAMPVA members.

Geisinger Health System – Magellan uses Magellan Care Guidelines as the primary decision support tool for the Geisinger UM program. They include the 20th edition Milliman Care Guidelines (MCG) for behavioral health acute services. They also include proprietary clinical criteria (Magellan Healthcare Guidelines) that Magellan has developed and maintains, for specialty behavioral outpatient services, and ASAM for substance use services.

Louisiana Coordinated System of Care (CSoC) Medical Necessity Criteria – medical necessity criteria for the Louisiana CSoC. 

Maryland Medical Necessity Criteria for Residential Crisis Services – criteria for residential crisis services for adults, adolescents and children whose insurance is written out of the state of Maryland.

Nebraska Medicaid Managed Care Program (NMMCP) and Nebraska Medical Assistance Program (NMAP) – you can find medical necessity criteria for serving these members in the appendix of Magellan's Provider Handbook Supplement for NMMCP and NMAP.

North Carolina Definition of Medically Necessary Services or Supplies – for North Carolina providers, this definition replaces Magellan’s definition in Magellan’s Medical Necessity Criteria and provider agreements.

Pennsylvania HealthChoices – information on medical necessity criteria for providers serving members of the HealthChoices Program in Pennsylvania can be found in the Pennsylvania HealthChoices provider handbook supplement and its applicable appendices.

Transcranial Magnetic Stimulation (TMS) Privileging Criteria (PDF) – Providers must meet the specified requirements for treatment of Major Depression using Transcranial Magnetic Stimulation (TMS).

State of Texas Standards for Reasonable Cost Control and Utilization Review for Chemical Dependency Treatment – criteria for all alcohol and substance abuse treatment services provided to members whose benefit plans are written in Texas.

Virginia DMAS Medical Necessity Criteria

Yale University (PDF) – Medical necessity criteria for members enrolled with Yale Health Plan.