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Clinical review
For information concerning whether a specific service or benefit is covered, please refer to your Evidence of Coverage, or call Kaiser Permanente Member Services toll-free at 1-800-464-4000
The documents below are available to detail the review process and procedures.
Please note that the materials provided to you below are guidelines used by this Plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
A
- Acupuncture UM Criteria Commercial (PDF)
- Acupuncture UM Criteria Medical EPSDT (PDF)
- Acupuncture UM Criteria Medicare (PDF)
D
- Dental Anesthesia UM Criteria Commercial (PDF)
- Dental Anesthesia UM Criteria Medi-Cal (PDF)
- Dental Anesthesia UM Criteria Medicare (PDF)
H
- Home Health Shift Care / Private Duty Nursing Services UM Criteria Commercial (PDF)
- Home Health Shift Care / Private Duty Nursing Services UM Criteria Medi-Cal EPSDT (PDF)
- Home Health Shift Care / Private Duty Nursing Services UM Criteria Medicare (PDF)
- Home Venipuncture Service UM Criteria Commercial (PDF)
- Home Venipuncture Service UM Criteria Medicare (PDF)
- Home Venipuncture Service UM Criteria Medi-Cal EPSDT (PDF)
O
- Occupational and Physical Therapy Services Commercial (PDF)
- Occupational and Physical Therapy Services Medi-Cal EPSDT (PDF)
- Occupational and Physical Therapy Services Medicare (PDF)
P
- Panniculectomy UM Criteria Commercial (PDF)
- Panniculectomy UM Criteria Medi-Cal EPSDT (PDF)
- Panniculectomy UM Criteria Medicare (PDF)
R
- Reduction Mammoplasty UM Criteria Commercial (PDF)
- Reduction Mammoplasty UM Criteria Medi-Cal EPSDT (PDF)
- Reduction Mammoplasty UM Criteria Medicare (PDF)
S