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)

COPD

Gold Reports for COPD Management (Global Initiative for Chronic Obstructive Lung Disease)

Diabetes

Standards of Medical Care in Diabetes (American Diabetes Association)

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

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

AACE/ACE Guidelines for Management of Dyslipidemia and Prevention of Cardiovascular Disease

American College of Cardiology (ACC) Guidelines and Clinical Documents

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

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) Guidelines

Obesity

Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults

American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity

American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society (AHA/ACC/TOS) Guideline for the Management of Overweight and Obesity in Adults

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

Cancer

National Comprehensive Cancer Network®

Immunizations and Preventive Services

CDC Catch-Up Immunization Schedule Who Start Late or Who Are More Than 1 Month Behind. Recommendations for ages 18 years or younger

CDC Adult Immunization Schedule. Recommendations for ages 19 years or older

CDC Vaccines for Children: Vaccines by Age

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

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

Anxiety

Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults, American Family Physician

Autism

Behavior Analyst Certification Board Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guideline for Healthcare Funders and Managers

Depression

American Psychiatric Association (APA) Practice Guideline for the Treatment Of Patients With Major Depressive Disorder (PDF)

Journal of Clinical Psychiatry Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression

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

Bipolar Disorder

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

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)

Trauma-Informed Care

Trauma Specific Services: A resource for implementation and use, Trauma Informed Oregon

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 Medication for the Treatment of Alcohol Use Disorder: A Brief Guide (pdf)