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Magellan Health

Medical Necessity Criteria

Magellan uses MCG Care Guidelines, along with our proprietary clinical criteria, Magellan Healthcare Guidelines, as the primary decision support tools for our Utilization Management Program. Collectively, they are known as the Magellan Care Guidelines.

Effective July 1, 2020, all plans use the 2020-2021 Magellan Care Guidelines unless noted in the State/Client-Specific Criteria section below.

All guidelines meet federal, state, industry accreditation, and customer contract requirements. They are based on sound scientific evidence for recognized settings of behavioral health services and are designed to decide the medical necessity and clinical appropriateness of services. 

Medical Necessity Criteria (effective July 1, 2020)

The 2020-2021 Magellan Care Guidelines (PDF) include:

  • Magellan Healthcare Guidelines -- These are publicly available at the link above.
  • MCG Care Guidelines -- These are proprietary; to view a copy of the MCG Care Guidelines, contact Magellan at the number on the member's benefit card, and a representative will send you a copy or grant you special online access.

Review a summary of changes (PDF) to the 2020-2021 Magellan Care Guidelines.

Archived Medical Necessity Criteria

2019-2020 Magellan Care Guidelines (PDF)

State/Client-Specific Criteria

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, contact the medical director at your Magellan Care Management Center.

American Society of Addiction Medicine (ASAM) 

Blue Cross and Blue Shield of Texas (under Health Care Service Corporation) – The 2020-2021 Magellan Care Guidelines apply with the following guideline modified for non-Medicare BCBSTX plans that cover TMS: Transcranial Magnetic Stimulation (PDF). 

Blue Shield of California - In addition to 2020-2021 Magellan Care Guidelines, the following apply for BSC members: Blue Shield of California Medical Policy for Behavioral Health Treatment for Autism Spectrum Disorders (PDF), Transcranial Magnetic Stimulation as a Treatment of Depression and Other Psychiatric/Neurologic Disorders (PDF) and Neuropsychological Testing (PDF).

California Review Criteria / Guidelines Grid (PDF) in compliance with Senate Bill 855

Louisiana Coordinated System of Care (CSoC) (PDF) 

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 – criteria for providers serving members of the HealthChoices Program in Pennsylvania can be found at

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

Virginia Department of Medical Assistance Service (DMAS)