Clinical review

Kaiser Foundation Health Plan of Georgia develops Internal Clinical Review Criteria to assist in administering plan benefits. These criteria neither offer medical advice nor guarantee coverage. For information concerning whether a specific service or benefit is covered, please refer to your Evidence of Coverage, or call Kaiser Permanente Member Services at 404-365-0966 or toll-free at 1-800-611-1811 (TTY 711).

Kaiser Permanente reserves the exclusive right to modify, revoke, suspend or change any or all criterion listed below, at Kaiser Permanente’s sole discretion, at any time.

Prior authorization (PA) is required before certain services are rendered to confirm medical necessity. No PA is required for emergency services. All services for out-of-network providers, except emergency services, require prior authorization. Decisions determine the medical necessity of a service and are not a guarantee of payment. Claims payment is determined by the member’s eligibility and benefits at the time the services are rendered.

By viewing these criteria, you acknowledge that you understand and accept the following:

• These Kaiser Permanente Clinical Review Criteria are technical and written to assist medical personnel in making coverage determinations. They are not medical advice, nor are they intended to influence the practitioner or alter his/her duty in any way to exercise his/her independent professional judgment in the care of members.
• The Kaiser Permanente Clinical Review Criteria are developed to identify eligibility for coverage when the patient's coverage contract includes the service/device.
• It should not be assumed that a patient meeting the criteria has coverage for the service/device. Please check the patient's coverage contract for specific exclusions or limitations.
• The criteria developed for use by Kaiser Permanente are based on the best available clinical evidence and regionally or nationally accepted standards.
• All Kaiser Permanente Clinical Review Criteria are reviewed at least annually. However, they are regularly updated and subject to change without notice. Service requests for a member are reviewed using the most current criteria.
• Kaiser Permanente has included the results of reviews conducted by the Kaiser Permanente Inter-regional New Technology Committee and the Regional Formulary & Therapeutics Committee. These committees, using evidence-based standards, review new technologies and treatments for medical efficacy. By including these reviews on this site, you will find that not all services are covered, and therefore some do not have approved criteria.
• Members and practitioners have the right to appeal coverage decisions. If the Kaiser Permanente medical director or his/her designee determines that a service is not covered, a notice will be issued to both the member and the practitioner. In addition to outlining the rationale for the denial, the notice will contain instructions for appealing the decision.

The documents below are available to detail the review process and procedures:

Kaiser Foundation Health Plan of Georgia utilizes the criteria hierarchy below to determine medical necessity and benefit coverage for Medicare members. 

• Evidence of Coverage
• Fully established Traditional Medicare coverage criteria
        o   Local Coverage Determination (LCD) Georgia region
        o   National Coverage Determination (NCD)
        o   Local Coverage Determination (LCD) -Non-Georgia region
        o   Medicare Benefit policy manuals
• MCG
• Kaiser Foundation Health Plan of Georgia Internal criteria
• Widely used peer reviewed treatment guidelines

Traditional Medicare coverage criteria can be accessed below.

• Medicare Coverage Database (NCD/LCD/NCA) (PDF)
         o   Local Coverage Determination (LCD) outside of Georgia’s service area
         o   LCD -Aortography and peripheral angiography (L36767)   
         o   LCD - Nerve Blockade for Treatment of Chronic Pain and Neuropathy (L35457) 
         o   LCD- Lumbar MRI (L37281)
• Medicare Benefit Policy Manual: Chapter 1 - Inpatient Hospital, Inpatient Rehabilitation Facility (IRF), Long Term Acute Care (LTAC) (PDF)
• Medicare Benefit Policy Manual: Chapter 7- Home Health Services (PDF)
• Medicare Benefit Policy Manual- Chapter 8, Skilled Nursing Facility (PDF)
• Medicare Benefit Policy Manual: Chapter 15 Covered Medical and Other Health Services (PDF)

Kaiser Foundation Health Plan of Georgia also utilize externally developed clinical criteria by MCG. Those documents can be reviewed here

Kaiser Foundation Health Plan of Georgia internally developed Clinical Review Criteria