Clinical Guidelines

Condition -- Asthma

Reference: “Guidelines for the Diagnosis and Management of Asthma” is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program. The Expert Panel Report 3 was initially published in July 2007.

Clinical Indicators:

  1. The percentage of members 18-85 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:
    • The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
    • The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, MMA)
  2. The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications of 0.50 or greater during the measurement year.
    (NOTE:  Medicaid, report only members 5-64 years of age.) (Source: HEDIS® 2017, Vol. 2, Technical Specifications, AMR)

Links:
http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

Condition -- Asthma – Child

Reference: Guidelines for the Diagnosis and Management of Asthma” is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program. The Expert Panel Report 3 was initially published in July 2007.

Clinical Indicators:

  1. Asthma Medication Ratio – Percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement.
        a.  SubMeasure– Percentage of members 5-21 years of age
    (Source: HEDIS 2017, Vol. 2, Technical Specifications, IET)
  2. Weight Assessment and counseling for nutrition and physical activity for children and adolescents, ages 3-17 years.  Patients 3-17 who had evidence of body mass index (BMI) percentile including height and weight, counseling or referral for nutrition or indication nutrition was addressed.  Counseling or referral for physical activity or indication physical activity was addressed during an OP visit either by a claim or as a medical record entry during the measurement year. 
    (Source: HEDIS 2017, Vol. 2, Technical Specifications, IET)
  3. Medication Management for People with Asthma.  Percentage of adults and adolescents 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate asthma controller medications that they remained on for at least 75% of treatment period.
        a.  SubMeasure– Percentage of members 5-21 years of age.
    (Source: HEDIS 2017, Vol. 2, Technical Specifications, IET)


Condition -- ADHD

Reference: October 2011 American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.

Clinical Indicators:

  1. The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported:
    -  Initiation Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase.
    Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. 
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, ADD)

Links:
http://pediatrics.aappublications.org/content/pediatrics/early/2011/10/14/peds.2011-2654.full.pdf

 

Condition -- Bipolar

Reference: American Psychiatric Association Clinical Practice Guideline titled “The Treatment of Patients with Bipolar Disorder,” Second Edition. (Revision 2002)

Clinical Indicators:

  1. The percentage of members 18–64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SSD)
  2. The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner: 
    a.   The percentage of discharges for which the member received follow-up within 30 days of discharge
    b.   The percentage of discharges for which the member received follow-up within 7 days of discharge.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, FUH)

Links:
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf
https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
https://www.network-health.org/uploadedFiles/pdfs/clinical_guidelines/guidelines_bipolar_watch.pdf

Condition -- BIPOLAR in Children and Adolescents

Reference:

American Academy of Child & Adolescent Psychiatry Clinical Practice Guideline titled “The Treatment of Children and Adolescents with Bipolar Disorder,” (January 2007).

Clinical Indicators:

  1. Metabolic Monitoring for Children and Adolescents on Antipsychotics
    (Source: HEDIS® 2017, Volume 2 Technical Specifications)
  2. Use of Multiple Concurrent Antipsychotics in Children and Adolescents
    (Source: HEDIS® 2017, Volume 2 Technical Specifications)

Links:
http://www.jaacap.com/article/S0890-8567(09)61968-7/pdf

Condition -- Childhood Obesity

Reference: Guideline for Prevention and Management of Obesity for Children and Adolescents”, July 2013. National Guideline Clearinghouse/AHRQ. - www.guidelines.gov/summaries/summary/47102/prevention-and-management-of-obesity-for-children-and-adolescents?q=childhood+obesity

Clinical Indicators:

  1. Weight Assessment and counseling for nutrition and physical activity for children and adolescents, ages 3-17 years. Patients 3-17 who had evidence of body mass index (BMI) percentile including height and weight, counseling or referral for nutrition or indication nutrition was addressed. Counseling or referral for physical activity or indication physical activity was addressed during an OP visit either by a claim or as a medical record entry during the measurement year.
    (Source: HEDIS 2017, Vol. 2, Technical Specifications, IET)Adult BMI (ABA) – population includes 18 and 19 year olds (HEDIS)
  2. Well Child Visits in the 3rd, 4th, 5th, and 6th Months of Life (W34) HEDIS
  3. Adolescent Well-Care Visits (AWC) HEDIS
  4. BMI greater than or equal to the following percentiles in children, ages 2 to 18. 
    a. 85th to 94th percentile
    b. Greater than or equal to the 95th percentile

Condition -- COPD

Reference:

The Global Initiative for Chronic Obstructive Lung Disease Guideline was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World Health Organization in 1998.

From the “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,” Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016.

Clinical Indicators:

  1. Percentage of members 40 years and older with a new diagnosis of COPD or newly active COPD, who have received spirometry testing to confirm the diagnosis. (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SPR)
  2. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 20 of the measurement year and who were dispensed a systemic corticosteroid within 14 days of the event.(Source: HEDIS® 2017, Vol. 2, Technical Specifications, PCE)
  3. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 30 of the measurement year and who were dispensed appropriate medications, and who dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event.  Note: The eligible population for this measure is based on acute inpatient discharges and ED visits, not on members. It is possible for the denominator to include multiple events for the same individual. (Source: HEDIS® 2017, Vol. 2, Technical Specifications, PCE)

Links:
http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/

Condition -- Cardiac

Reference:

  1. 2013 ACC/AHA Guideline on Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
  2. 2013 ACCF/AHA Guideline for the Management of Heart Failure
  3. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary & Other Atherosclerotic Vascular Disease: 2011 Update.
  4. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Clinical Indicators:

  1. The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. (Source: HEDIS® 2017, Vol. 2, Technical Specifications, PBH)
  2. The percentage of males 21-75 and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who:
    a.    Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year. 
    b.    Met statin adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SPC)

Links:
Management of Adults with Elevated Cholesterol
Management of Patients with Heart Failure
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
Management of Patients with CAD

Condition -- Colitis/Crohn’s Disease

Reference:

  1. Real-world Assessment of Therapy Changes, Suboptimal Treatment and Associated Costs in Patients with Ulcerative Colitis or Crohn’s Disease

Clinical Indicators:

  1. Number of Members who are diagnosed with:
    a.    Crohn’s Disease 
    b.    Colitis
    c.    Irritable Bowel Syndrome
  2. Decreased number of ER visits for members with Crohn’s Disease or Colitis and underlying symptoms. (Monthly Claims from ER visits with the following ICD-10 codes:
    - K50.XXX-Crohn’s Disease
    - K51.XXX-Colitis
    - K58.XXX-Irritable Bowel Syndrome
    - R10.31 Right lower quadrant abdominal pain 

Links:
http://onlinelibrary.wiley.com/doi/10.1111/apt.12727/epdf

Condition -- Diabetes

Reference: American Diabetes Association’s (ADA) “Standards of Medical Care in Diabetes-2016” for its Diabetes Guideline (January 2017).

Clinical Indicators:

  1. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:
    • Hemoglobin A1c (HbA1c) testing
    • HbA1c poor control (>9.0%)
    • HbA1c control (<8.0%)
    • HbA1c control (<7.0%) for a selected population
    • Eye exam (retinal) performed
    • Medical attention for nephropathy
    • BP control (<140/90 mm Hg)
      (Source: HEDIS® 2017, Vol. 2, Technical Specifications, CDC)
  2. The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who were dispensed at least one statin medication of any intensity during the measurement year.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SPD)
  3. The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who remained on a statin medication of any intensity for at least 80% of the treatment period.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SPD)

Links:
http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf
 

Condition -- Depression

Reference: Institute for Clinical Systems Improvement Health Care Guideline titled, “Major Depression in Adults in Primary Care” (Seventeenth Edition, March 2016)

Clinical Indicators:

  1. The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment.
  • Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
  • Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).

(Source: HEDIS® 2017, Vol. 2, Technical Specifications, AMM)

Links:
Institute for Clinical Systems Improvement Health Care Guideline Adult Depression in Primary Care 
US Department of Health and Human Services/Agency for Healthcare Research and Quality (AHRQ) – “Adult Depression in Primary Care”

Condition -- HAE (Hereditary Angioedema)

Reference: Diagnosis and Screening of Patients with Hereditary Angioedema in Primary Care” WAO Guideline for the Management of Hereditary Angioedema published in Therapy Clinical Risk Management 2016;12:701-711. NCBI/NIH (published online 2016 May 2) 

Clinical Indicators:

  1. All hereditary angioedema members under the age of 21 will adhere to EPSDT periodicity schedule and receive age-appropriate immunizations
  2. Provide intensive education on home-infusion treatment to ensure parents/guardians are successful in adhering to self-infusion regimen
  3. All pharmacy providers will adhere to management of pharmacy agents prescribed.
  4. Educate HAE members with Medical Alert Identification card and member to obtain a signed letter from a physician with emergent treatment for HAE attacks.

Links:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859422/
http://www.angioedemacenter.com/DOCS/HAEBrochure2014.pdf

Condition -- Hemophilia

Reference: Guidelines for the management of hemophilia. 2nd ed. Montreal (Quebec): World Federation of Hemophilia; 2012. 74 p. [324 references]

Clinical Indicators:

  1. 100% of all members identified with hemophilia will become actively engaged in care coordination services
  2. Members will be 100% compliant with established prophylactic dosing schedule
  3. Members will have a 50% reduction in joint and other bleeds annually (Individual baselines will be established)
  4. Members will have a 25% reduction in hospital admissions associated with joint and/or other spontaneous bleeds
  5. 100% of members participating in care coordination services will  keep a  monthly log of all bleeds, medication use, and history of injuries

Links:
http://www1.wfh.org/publications/files/pdf-1472.pdf

Condition -- HIV

Reference: "Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” is a national guideline, following the recommendations by the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents - A Working Group of the Office of AIDS Research Advisory Council (OARAC).

This guideline describes the best clinical practices based on available knowledge and a consensus of experts as of July 14, 2016. Health Resources and Services Administration (HRSA), Measure HVL-AD: HIV Viral Load Suppression, as presented in the Core Set of Health Care Quality Measures for Adults Enrolled in Medicaid 2017 Technical Specifications and Resource Manual

Clinical Indicators:

  1. Number of HIV+ individuals with at least one outpatient visit in the past 12 months.
  2. Percentage of enrollees age 18 and older with a diagnosis of Human Immunodeficiency Virus (HIV) who had a HIV viral load test during the measurement year. (Health Resources and Services Administration)
  3. Percentage of Enrollees with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links:
https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf
http://aidsinfo.nih.gov/guidelines
https://www.medicaid.gov/medicaid/quality-of-care/downloads/2017-adult-core-set.pdf

Condition -- Hypertension

Reference: "2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: :  Report From the Panel Members Appointed to the Eighth Joint National Committee” (JNC 8).

Clinical Indicators:

  1. Percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria: 
    • Members 18-59 years of age whose BP was <140/90 mm Hg.
    • Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
    • Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.

(Source: HEDIS® 2017, Vol. 2, Technical Specifications, CBP)

Links:
http://jama.jamanetwork.com/article.aspx?articleid=1791497

Condition -- Adult Preventive

Reference: Highmark Health Options follows the Centers for Disease Control and Prevention, recommended Adult Immunization Schedule-United States, 2017. The Adult Immunization Schedule has been approved by ACIP, ACOG, ACP & AAFP.

Clinical Indicators:

  1. The percentage of women 50–74 years of age who had a mammogram to screen for breast cancer.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, BCS)
  2. The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, ABA)

Links:
Adult Guidelines
Immunization
Recommended Vaccinations Indicated for Adults Based on Medical and Other Indications"  

Condition -- Child Preventive

Reference: 2016 Bright Futures/AAP Periodicity Schedule, and CDC Immunization Schedule Birth-18 Years and Catch-up

Clinical Indicators:

  1. The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP during their first 15 months of life:
    • No well-child visits.
    • One well-child visit.
    • Two well-child visits.
    • Three well-child visits.
    • Four well-child visits.
    • Five well-child visits.
    • Six or more well-child visits.
      (Source: HEDIS® 2016, Vol. 2, Technical Specifications, W15)
  2. The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year. (Source: HEDIS® 2017, Vol. 2, Technical Specifications, AWC)
  3. The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); (Combo 3)
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, CIS)

Links:
Child Preventive Guideline, Summary of Changes
Bright Futures/AAP Periodicity Schedule
CDC Immunization Schedule

Condition -- Opioid Dependency

Reference:

CDC Guideline for Prescribing Opioids for Chronic Pain - https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf

Clinical Indicators:

  1. Number of members who received a urine drug test prior to being prescribed opioids for chronic pain
  2. Number of members prescribed opioid pain medication and benzodiazepines concurrently.
  3. Provide education on the risks of prescription drug use to avoid misuse.
  4. Ensure responsible prescribing practices including increased education of providers and prescribers to better understand how medications can be misused and to identify members in need of treatment.
  5. Educate providers on utilizing the Delaware Prescription Monitoring Program (PMP).

Condition -- Palliative Care

Reference: Clinical Practice Guidelines for Quality Palliative Care,” 2013, 3rd Edition, based on the National Consensus Project for Quality Palliative Care. 

Clinical Indicators:

  1. Documentation of Evidence of Advanced Directives
  2. Number of Patients Screened for Palliative Care Needs
  3. Percent of Documentation of Pain Assessment

Links:
http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf

Condition -- Routine and High Risk Prenatal Care

Reference: Updated ACOG Bulletins from 2016 and 2017, ACOG News Room Practice Advisories and ACOG Committee Opinions

Clinical Indicators:

  1. The percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that had the following number of expected prenatal visits:
    • < 21% of expected visits
    • 21%-40% of expected visits
    • 41%-60% of expected visits
    • 61%-80% of expected visits
    • ≥ 81% of expected visits
      (Source: HEDIS® 2017, Vol. 2, Technical Specifications, FPC)
  2. The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year.·

    • Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.
    • ·Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
      (Source: HEDIS® 2017, Vol. 2, Technical Specifications, FPC)

Links:
Routine and High Risk Prenatal Care
https://www.acog.org/About-ACOG/News-Room/Practice-Advisories
https://www.acog.org/Resources-And-Publications/Committee-Opinions-List

Condition -- Schizophrenia

Reference: American Psychiatric Association’s Clinical Practice Guideline, “The Treatment of Patients with Schizophrenia,” Second Edition, (2004).

Clinical Indicators:

  1. The percentage of members 18–64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year. (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SMC)
  2. The percentage of members 18–64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year. (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SMD)
  3. The percentage of members 18-64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year. (Source: HEDIS® 2017, Vol. 2, Technical Specifications, SSD)

Links:
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia-watch.pdf

Condition -- Schizophrenia in Children and Adolescents

Reference: “Practice Parameters for the Assessment and Treatment of Children and Adolescents with Schizophrenia”, Volume 52, Number 9 September 2013

Clinical Indicators:

  1. The percentage of children and adolescents 1-17 years of age who had two or more antipsychotic prescriptions and had metabolic testing. Metabolic Monitoring for Children and Adolescents on Antipsychotics.
  2. The percentage of children and adolescents 1–17 years of age who were on two or more concurrent antipsychotic medications.Use of Multiple Concurrent Antipsychotics in Children and Adolescents (Source: HEDIS® 2017, Volume 2 Technical Specifications, APC)

Links:
http://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Schizophrenia_Sept13.pdf

Condition -- Sickle Cell Disease

Reference: “The Management of Sickle Cell Disease”, The National Institutes of Health, National heart, Lung, and Blood Institute NIH Publication No. 02-2117 June 2002 (Fourth Edition)

Clinical Indicators:

  1. Percentage  of members who are compliant with the seasonal flu shot (total and by race/ethnicity breakdown)
  2. Number of school or work days missed by persons with sickle cell disease due to sickle cell crisis exacerbation/complications/100 members

Links:
http://www.nhlbi.nih.gov/files/docs/guidelines/sc_mngt.pdf
http://www.nejm.org/doi/full/10.1056/NEJM199904013401307

Condition -- Substance Abuse

Reference: American Psychiatric Association’s “Practice Guideline For The Treatment of Patients With Substance Use Disorders,” Second Edition, (2006).

Clinical Indicators:

  1. Initiation of AOD Treatment. Percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.(Source: HEDIS® 2017, Vol. 2, Technical Specifications, IET)
  2. Engagement of AOD Treatment. Percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
    (Source: HEDIS® 2017, Vol. 2, Technical Specifications, IET)

Links:
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf

General Guideline Limitations:

  • Guidelines may not apply to every patient or clinical situation; some variation from guidelines is expected. Provider judgment and knowledge of an individual patient supersedes clinical guidelines.
  • Guidelines do not determine insurance coverage of health care services or products. Coverage decisions are based on member eligibility, contractual benefits, and determination of medical necessity.