The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. Guideline determinations are made based on the information provided at the time of the request.

In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. The Carelon Guidelines are just guidelines for the provision of specialty health services. Although the Guidelines are publicly-available, Carelon considers the Guidelines to be important, proprietary information of Carelon, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of Carelon.Ĭarelon applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. Copies of the Carelon Clinical Appropriateness Guidelines are also available upon oral or written request. Carelon reviews all of its Guidelines at least annually.Ĭarelon makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Relevant citations are included in the References section attached to each Guideline. The Carelon guideline development process complies with applicable accreditation standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. To promote the most efficient and cost-effective use of services To curtail the performance of inappropriate and/or duplicate services To encourage standardization of medical practice patterns To assist the practitioner as an educational tool To establish criteria for when services are medically necessary (i.e., in general, shown to be effective in improving health outcomes and considered the most appropriate level of service) In the process, multiple functions are accomplished: As used by Carelon, the Guidelines establish objective and evidence-based criteria for medical necessity determinations where possible. The Carelon Clinical Appropriateness Guidelines (hereinafter “the Carelon Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. History Description and Application of the Guidelines Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions All rights reserved.ĭescription and Application of the Guidelines

© 2022 Carelon Medical Benefits Management, Inc. Please consult the applicable health plan for more details.Īppropriate Use Criteria: Vascular Imaging It is for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the Carelon Medical Benefits Management website at:Īpproval and implementation dates for specific health plans may vary. This document has been archived because it has outdated information.

Cpt code for carotid doppler ultrasound