Clinical Policies and Practice Guidelines

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

Oregon Prioritized List of Health Services

Medicare and Medicaid

National Coverage Determination (NCD) and Local Coverage Determination (LCD)

Commercial and Medicare

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
- ECSII Guide for Patients, Families, and Providers (PDF)

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)

Autoimmune Disease

American College of Rheumatology (ACR): Lupus Clinical Practice Guidelines

American College of Rheumatology (ACR): Rheumatoid Arthritis Clinical Practice Guidelines

Cancer

National Comprehensive Cancer Network®

U.S. Preventive Services Task Force: Cancer Screening Recommendations

COPD

Gold Report for COPD Management (Global Strategy for Prevention, Diagnosis, and Management of COPD)

Coronary Artery Disease

ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Recent Innovations, Modifications, and Evolution of ACC/AHA Clinical Practice Guidelines: An Update for Our Constituencies: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

American Association of Clinical Endocrinology (AACE) Clinical Practice Guideline on Pharmacologic Management of Adults With Dyslipidemia

American College of Cardiology (ACC) Guidelines and Clinical Documents

Diabetes

Standards of Care in Diabetes (Standards of Care)

American Association of Clinical Endocrinologists Practice Guidelines (AACE) Clinical Guidance: Diabetes

Heart Failure

Guidelines for the Management of Heart Failure (American College of Cardiology, American Heart Association Task Force, and the Heart Failure Society of America on Clinical Practice Guidelines)

American College of Cardiology (ACC) Guidelines and Clinical Documents

Hypertension

American College of Cardiology: ACC/AHA (multiple organizations) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults Abstract | Full Guideline

Immunizations and Preventive Services

American Academy Family Physicians (AAFP) Immunization Schedules

U.S. Preventive Services Task Force (USPSTF): Recommendations for primary care and prevention

Inflammatory Bowel Disease

American College of Gastroenterology (ACG) Clinical Guideline: Management of Crohn's Disease in Adults

American College of Gastroenterology (ACG) Clinical Guideline: Ulcerative Colitis in Adults

Long term (current) drug therapy (polypharmacy)

American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults

Deprescribing Guidelines and Algorithms

Obesity

Academy of Nutrition and Dietetics: Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline

American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE): Clinical guidance

Obesity Medicine Association Clinical Guidelines and Resources

AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity

American Academy of Pediatrics (AAP) Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity

Pain

Centers for Disease Control and Prevention (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain

Oregon Pain Guidance (OPG) Pain Treatment Guidelines

Pediatrics

Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care / Periodicity Schedule

Prenatal

American College of Obstetricians and Gynecologists Clinical Information (ACOG)

American College of Obstetricians and Gynecologists Clinical Guidance: Obstetric Care Consensus (ACOG and the Society for Maternal-Fetal Medicine (SMFM))

Breastfeeding Centers for Disease Control and Prevention (CDC) Recommendations and Guidance

Seizure Disorders

International League Against Epilepsy (ILAE): Updated Classification of Epileptic Seizures

American Academy of Neurology (AAN): Management of Functional Seizures

Anxiety

American Association of Psychiatric Pharmacists (AAPP): Treatment Guidelines: Anxiety and related disorders

Attention-deficit / hyperactivity disorder (ADHD) Children and Adolescents

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit/Hyperactivity disorder in Children and Adolescents, American Academy of Pediatrics

Attention-deficit / hyperactivity disorder (ADHD) Adults

Attention deficit hyperactivity disorder: diagnosis and management, NICE guideline [NG87], National Institute for Health and Care Excellence

Autism Spectrum Disorder

Applied behavior analysis practice guidelines for the treatment of Autism Spectrum Disorder: Guidance for healthcare funders, regulatory bodies, service providers, and consumers [Clinical practice guidelines]

Bipolar Disorder

Bipolar disorder: assessment and management, Clinical guideline [CG185], National Institute for Health and Care Excellence.

Depression

The American Association of Psychiatric Pharmacists (AAPP): Depression Treatment Guidelines

Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of repetitive transcranial magnetic stimulation (pdf)

Eating Disorders

APA Practice Guideline for the Treatment of Patients with Eating Disorders (pdf)

Gender-Affirming Care

Standards of Care for the Health of Transgender and Gender Diverse People, The World Professional Association for Transgender Health

Psychotic Disorders

Practice Guideline for the Treatment of Patients with Schizophrenia, American Psychiatric Association

Practice Guidelines for Oregon Early Assessment and Support Alliance

Strategies to Promote Best Practice in Antipsychotic Prescribing for Children and Adolescents, SAMHSA (pdf)

Substance Use Disorders

The American Society of Addiction Medicine Patient Placement Criteria for the Treatment of Substance-Related 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 Advisory: Prescribing Pharmacotherapies for Patients with Alcohol Use Disorder (pdf)

Trauma-Informed Care

Trauma Informed Oregon: Implementation and Accountability Overview

Oral Health Policies & Recommendations (The Reference Manual of Pediatric Dentistry), The American Academy of Pediatric Dentistry

Clinical Practice Guidelines and Dental Evidence, The American Dental Association (ADA) Center for Evidence-Based Dentistry

U.S. Preventive Services Task Force (USPSTF) Recommendation Statement: Prevention of Dental Caries in Children Younger than 5 Years: Screening and Interventions

Oral Health in Children and Adolescents Aged 5 to 17 Years: Screening and Preventive Interventions

Oral Health in Adults: Screening and Preventive Interventions

Clinical policies and practice guidelines