Prior Authorization
Clover’s Internal Coverage Criteria
Where criteria for coverage are not fully established in applicable Medicare statutes, regulations, National Coverage Determinations, or Local Coverage Determinations, Clover may rely on internal coverage criteria in evaluating pre-authorization requests for products or services for which coverage may be available under Original Medicare. Clover has adopted as its internal coverage criteria guidelines developed by its vendors, with different vendors’ guidelines used for different categories of products and services. Please refer to the below list for the designated vendor for specific categories of products or services, and for information on how you can access the guidelines.
| Vendor | Applicable Products & Services | How to Access Coverage Criteria |
|---|---|---|
| Novologix | Medicare Part B Drugs | Available HERE |
| Evicore |
Pain and joining surgery |
Available HERE |
| MCG | Please see the table below for MCG guidelines adopted by Clover as internal coverage criteria |
In order to access the MCG guidelines used by Clover you will need to request a one-time username and passcode by calling one of the following numbers: Provider Services: 1-877-853-8019 (TTY 711) Once you obtain that information, please enter it into the pertinent forms on the web page linked HERE |
| MCG Guidelines Used by Clover |
|---|
| ORG: S-1310 (ISC) Percutaneous Revascularization, Lower Extremity |
| ACG: A-0395 (AC) Gastric Stimulation (Electrical) |
| ACG: A-0801 (AC) Renal Cancer (Hereditary) - Gene Panel |
| ACG: A-0353 (AC) Wheelchairs, Power |
| ACG: A-0407 (AC) Cranial Orthotic Devices |
| ACG: A-0701 (AC) Myoelectric Prosthesis |
| ACG: A-0773 (AC) Colorectal Cancer-Gene Testing (Somatic or Therapeutic) |
| ACG: A-0795 (AC) Non-Small Cell Lung Cancer-Gene Testing (Somatic or Therapeutic) |
| ACG: A-0649 (AC) HLA Pharmacogenetics-HLA Testing |
| ACG: A-0709 (AC) Proteomics-Ovarian Cancer Biomarker Panel (OVA 1) |
| ACG: A-0693 (AC) Proteomics (VeriStrat) |
| ACG: A-0195 (AC) Blepharoplasty, Canthoplasty, and Related Procedures |
| GRG: SG-MS (ISC GRG)Musculoskeletal Surgery or Procedure GRG |
| ACG: A-0247 (AC) Mandibular Osteotomy |
| GRG: SG-HNS (ISC GRG) Head and Neck Surgery or Procedure GRG |
| GRG: SG-TS (ISC GRG) Thoracic Surgery or Procedure GRG |
| ORG: S-1210 (ISC) Wrist Arthroplasty |
| ORG: S-710 (ISC) Knee Arthrotomy |
| ACG: A-0492 (AC) Temporomandibular Joint Arthroscopy |
| GRG: SG-NS (ISC GRG) Neurosurgery or Procedure GRG |
| ACG: A-0893 (AC)Home Ventilator (Invasive or Noninvasive Interface) |