Clinical policies
External clinical guidelines
There may be more than one set of criteria available for any given procedure or service. Medical necessity determinations under the applicable health plan benefit are based on a hierarchy of clinical policies and care guidelines.
Criteria developed by the following external entities may be used as indicated or when no PacificSource clinical policy or applicable Medicaid or Medicare guideline exists.
Medicaid
Medicare and Medicaid
Commercial and Medicare
Musculoskeletal
Commercial, Medicare, and Medicaid
- MCG Care Guidelines
Radiology
Genetic testing
Substance use disorders
Level of care for primary mental health diagnoses
- For adults ages 19 years and older: The Level of Care Utilization Services Tool (LOCUS) by the American Association for Community Psychiatry
- For children and adolescents ages 6 to 18 years: The Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) by the American Association for Community Psychiatry and the American Academy of Child and Adolescent Psychiatry
- For children five years of age and younger: The Early Childhood Service Intensity Instrument (ECSII) by the American Academy of Child and Adolescent Psychiatry
Practice guideline adoption and recommended use
PacificSource Community Solutions, PacificSource Medicare, and PacificSource Health Plans support the use of practice guidelines based on nationally recognized, valid, and reliable evidence-based clinical literature or a consensus of professionals in a particular field.
PacificSource adopts medical, behavioral, and oral health guidelines to assist providers and members in making decisions about appropriate healthcare choices. PacificSource practice guidelines are not meant to replace the clinical judgment of a treating provider. Guidelines are reviewed and updated as needed on an annual basis.
In all cases, benefit determinations should be based on the applicable contract coverage. Should there be any discrepancy between these guidelines and the contract language, the contract language will take precedence.
Asthma
GINA Report, Global Strategy for Asthma Management and Prevention (Global Initiative for Asthma)
COPD
Gold Reports for COPD Management (Global Initiative for Chronic Obstructive Lung Disease)
Diabetes
Standards of Care in Diabetes (Standards of Care)
Coronary Artery Disease
AACE/ACE Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease
American College of Cardiology (ACC) Guidelines and Clinical Documents
Heart Failure
American College of Cardiology (ACC) Guidelines and Clinical Documents
Prenatal
American College of Obstetricians and Gynecologists Clinical Information (ACOG)
Centers for Disease Control and Prevention (CDC) Breastfeeding Recommendations and Guidance
Obesity
AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity
Pain
Northwest Pain Guidance Practice Guides
Cancer
National Comprehensive Cancer Network®
Long term (current) drug therapy (polypharmacy)
Deprescribing Guidelines and Algorithms
Immunizations and Preventive Services
CDC Child and Adolescent Immunization Schedule by Age. Recommendations for Ages 18 Years or Younger
CDC Adult Immunization Schedule by Age. Recommendations for Ages 19 Years or Older
U.S. Preventive Services Task Force (USPSTF): Recommendations for primary care and prevention
Attention-deficit / hyperactivity disorder (ADHD) Children and Adolescents
Attention-deficit / hyperactivity disorder (ADHD) Adults
Anxiety
Autism Spectrum Disorder
Depression
Eating Disorders
APA Practice Guideline for the Treatment of Patients with Eating Disorders (pdf)
Gender-Affirming Care
Bipolar Disorder
Psychotic Disorders
Practice Guidelines for Oregon Early Assessment and Support Alliance
Trauma-Informed Care
Trauma Informed Oregon: Implementation and Accountability Overview
Substance Use Disorders
SAMHSA TIP (Treatment Improvement Protocols) 63: Medications for Opioid Use Disorder For Healthcare and Addiction Professionals, Policymakers, Patients, and Family:Executive Summary (pdf), Full Document (pdf)
SAMHSA Medication for the Treatment of Alcohol Use Disorder: A Brief Guide (pdf)