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
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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.
The 2022 update of the Global Strategy for Asthma Management and Prevention incorporates new scientific information about asthma based on a review of recent scientific literature by an international panel of experts on the GINA Science Committee. Visit the Global Initiative for Asthma site for GINA report download.
It is anticipated that Primary Care Physicians will initially care for back pain patients themselves using the evaluation, treatment and referral guidelines. Download back pain care guidelines.
Bone mineral density (BMD) testing with DXA should be performed: • NOF and USPSTF guideline: In women age 65 and older and men age 70 and older (USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men). Download bone mineral density measurement guidelines
The following recommendation is based upon the current national guidelines for Chlamydia screening:
- Annual chlamydia screening of all sexually active* women younger than 25 years, as well as older women with risk factors such as new or multiple sex partners, or a sex partner who has a sexually transmitted infection. The recommended screening test at UCLA is PCR. Download Chlamydia screening guidelines.
The UCLA Medical Group recommends routine screening for colorectal cancer in males and females ages 45 through 80, screening at younger ages if sufficient risk factors are present, and generally stopping routine screening after age 80. Download colonoscopy guidelines.
Heart failure (HF) affects over 6 million patients in the US, with 1 million new cases occurring annually and a resultant 900,000 hospitalizations with a primary discharge diagnosis, which translates into an annual estimated cost of over $30 billion dollars. Mortality with this condition is high, approximately 50% at 5 years. Implementation of the advances in management of heart failure have the potential to improve patients' quality of life, reduce the need for hospitalizations, reduce total medical costs, and prolong survival. Download congestive heart failure guidelines.
the new criteria for AD (Alzheimer's disease) are presented in three new documents, although the process is a continuous one with sometimes difficult-to-define boundaries between each discrete category. The evidence for preclinical AD is based almost entirely on AD biomarkers. Criteria for the earliest symptomatic manifestations, the MCI stage, represent a sharpening of previous efforts to define MCI. The MCI criteria also define an entity of MCI owing to AD-P, based on the conjunction of the clinical diagnosis and the presence of AD-P biomarkers. Download Dememtia treatment 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 guidelinesThis guideline outlines the common care issues related to diabetic non-pregnant adults. This guideline seeks to reconcile the differences in the recommendations of the specialty groups most involved with the care of diabetes (i.e. primary care, endocrinology, cardiology and nephrology). Download diabetes care guidelines.
Primary Care Physician Responsibility:
For the following common diagnoses, the Primary Care Physician should perform the history and physical and initiate treatment. Only if the diagnosis is unclear, or if the patient does not respond to treatment as expected, should a referral be submitted for an initial consultation with ENT/Head & Neck Surgery. After the Surgeon 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. This list covers the more common conditions, and should not imply that these are the only ENT/Head & Neck conditions that PCPs can and should treat. Download ENT-Otolaryngology care guidelines.Tuberculosis remains an important preventable disease in the United States. The precise prevalence rate of LTBI (Latent TB Infection) in the United States is difficult to determine; however, based on 2011–2012 National Health and Nutrition Examination Survey data, estimated prevalence is 4.7% to 5.0%.1 Tuberculosis is spread through respiratory transmission. Approximately 30% of persons exposed to Mycobacterium tuberculosis will develop LTBI, and, if untreated, approximately 5% to 10% of these persons will progress to active tuberculosis disease.2-5 Rates of progression may be higher in persons with certain risk factors or medical conditions. An important strategy to reduce the transmission, morbidity, and mortality of active tuberculosis disease is the identification and treatment of latent TB to prevent its progression to active disease. (USPSTF, 2016. Download Latent TB Infection (LTBI) Testing guidelines
The UCLA Medical Group has adopted a guideline that combines the USPSTF and ACS breast cancer screening guidelines.
- For women aged 39 or less, authorization is required.
- For women aged 40-74, every 1-2 years without preauthorization.
- For women 75 and older, mammography may be ordered every 1-2 years if clinically appropriate without preauthorization.
MOHs 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.
Patients initially evaluated and treated in the Emergency Room for fractures may be referred to an Orthopedist without further PCP evaluation in a time period as outlined in the section on Outpatient Fracture Care.
In general all other problems; It is expected that the Primary Care Physician will perform a history and physical and initiate treatment prior to referral. If the diagnosis is unclear, or if the patient does not respond to treatment as expected, or if the referral indications are met a referral should be submitted for an initial consultation. This list covers the more common conditions, but there may be other orthopedic conditions that PCPs can and should initially treat. Download orthopedic and sports medicine 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.
Treatment of nail problems, structural deformities, forefoot pain, heel pain, skin leasions, and ankles. Download podiatry care 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
For the following common diagnoses, the Primary Care Physician should perform the history and physical and initiate treatment. Only if the diagnosis is unclear or if the patient does not respond to treatment as expected, should a referral be submitted for an initial consultation with the Urologist. This guideline relates to some common conditions, but there may be other urologic conditions that PCPs can and should treat. Download urology care 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