UCLA Medical Group Medical Management Guidelines
CMS Guidelines - Medicare Coverage Database (MCD)
The Medicare Coverage Database contains information related to what's covered and not covered by Medicare.
InterQual Evidence Based Criteria
InterQual is an evidence-based clinical decision support solution for payers, providers, and government agencies who want to help ensure clinically appropriate medical-utilization decisions.
MCG Evidence Based Criteria
MCG solutions support clinical decisions that help patients get the right level of care. MCG care guidelines are the protected intellectual property of MCG and has provided a tool that allows UCLA Medical Group members and prospective members to view relevant MCG care guidelines.
Medical Guidelines & Clinical References
Internal clinical based guidelines to support clinically appropriate medical utilization decisions.
UCLA Medical Group may approve the use of acupuncture for following conditions:
- Chronic pain due to osteoarthritis of the knee, hip, or Lumbar Spine
- Nausea and vomiting associated with surgery, chemotherapy or pregnancy
- Other conditions that are covered by the member’s Health Plan, if criteria are met.
- For patients with a Medicare Advantage (Senior) plan, UCLA will follow Medicare guidelines.
Primary Care Physician Responsibility:
For the following diagnoses, in the majority of cases, the Primary Care Physician should perform the history and physical and initiate treatment. Only if the diagnosis is unclear or if patient does not respond to treatment as expected, should a referral be submitted for an initial consultation with the Dermatologist. After the Dermatologist has evaluated and diagnosed the patient, he/she will determine the need to continue treatment under his/her care or refer the patient back to the PCP to continue the recommended treatment plan. Download dermatology care guidelinesMOHs surgery for the following:
- Skin cancers in immunocompromised patients (organ transplants and chronic lymphocytic leukemia patients are most common in UCLA).
- Skin cancers in tumor genetic syndromes (e.g. Gorlins, Lynch, Cowden, etc)
The intent of this policy is to address anesthesia services for diagnostic and therapeutic procedures performed in an outpatient setting. Various levels of anesthesia, including sedation and analgesia, may be used depending on the patient’s condition and the procedure being performed. This policy addresses the need for Monitored anesthesia care (MAC). Download monitored anesthesia care guidelines.
Provide an evidence based clinical policy for pharmacologic treatment of osteoporosis. Download osteoporosis treatment guidelines.
Establish an evidence based clinical policy for pain alleviating procedures in the UCLA managed care population in order to standardize care and processes across settings, specialties, health plans, lines of business, providers and UM reviewers. Download pain procedure policy guidelines.
Provide an evidence-based clinical policy for appropriate administration of Pegfilgrastim in the outpatient setting. Pegfilgrastim is an FDA approved leukocyte growth factor. Download pegfilgrastim administration guidelines.
Radiofrequency ablation of a tumor involves the delivery of high-frequency alternating current to induce thermal injury of target tissue. It may be performed percutaneously, transcervically, or surgically via laparoscopy or laparotomy; the procedure is performed with CT, MRI, or ultrasound guidance. Establish an evidence based clinical policy for Radiofrequency Ablation of Leiomyoma’s (Fibroids) in the UCLA managed care population in order to standardize care and processes across settings, specialties, health plans, lines of business, providers and UM reviewers. Download radiofrequency ablation of leiomyomas guidelines
Establish an evidence based clinical policy for weight management and obesity management in the UCLA managed care population in order to standardize care and processes across settings, specialties, health plans, lines of business, providers and UM reviewers. Download weight management and obesity treatment guidelines