Coverage policies are tools to assist in interpreting standard health coverage plan provisions.

Coverage is based on:

• • Medicare national coverage determinations (NCDs)
  • Local coverage determinations (LCDs)
  • The member’s applicable Medicare Evidence of Coverage (EOC) and Summary of Benefits (SOB)

In the absence of an applicable national coverage determination, local coverage determinations, or other CMS-published guidance, Sanford Health Plan uses medical policies based on credible scientific evidence published in peer-reviewed medical literature. These Sanford Health Plan coverage summaries apply to Align powered by Sanford Health Plan Medicare Advantage plans.

Sanford Health Plan uses vendor guidelines for certain products to support utilization management review of certain services.

Access MCG care guidelines online using the link below. You will be asked to check the Terms and Conditions box, select Accept and Proceed, and then enter your username and contact information. After completing these steps, you will receive an access code via your preferred method.

Access Coverage Policies

Coverage policies are tools to assist in interpreting standard health coverage plan provisions.

Coverage is based on:

• • Medicare national coverage determinations (NCDs)
  • Local coverage determinations (LCDs)
  • The member’s applicable Medicare Evidence of Coverage (EOC) and Summary of Benefits (SOB)

In the absence of an applicable national coverage determination, local coverage determinations, or other CMS-published guidance, Sanford Health Plan uses medical policies based on credible scientific evidence published in peer-reviewed medical literature. These Sanford Health Plan coverage summaries apply to Align powered by Sanford Health Plan Medicare Advantage plans.

Sanford Health Plan uses vendor guidelines for certain products to support utilization management review of certain services.

• • Ambulance: Land and Air Transportation Medical Policy
  • Autologous Cultured Chondrocytes Medical Policy
  • Back Surgical Procedures: Cervical and Thoracic Spinal Levels – Inpatient and Outpatient Settings Medical Policy
  • Back Surgical Procedures: Lumbar Spinal Level – Inpatient and Outpatient Settings Medical Policy
  • Back Surgical Procedure for Vertebroplasty – Inpatient and Outpatient Settings Medical Policy
  • Behavioral Health/Substance Use Disorder (SUD) Treatment – Medicare Advantage Medical Policy
  • Bone and Tendon Graft Substitutes and Adjuncts Medical Policy
  • Bone Growth Stimulator for the 5th Metatarsal Medical Policy
  • Breast Reconstruction Post-Mastectomy Medical Policy
  • Breast Reduction Mammoplasty Medical Policy
  • Complementary and Alternative Medicine Medical Policy
  • Cosmetic Surgery/Treatments Medical Policy
  • Experimental or Investigational Medical Policy
  • Gender-Affirming Medical and Surgical Treatment Medical Policy
  • Genetic Testing: Cardiovascular Medical Policy
  • Genetic Testing: Dermatology Medical Policy
  • Genetic Testing: Neurology Medical Policy
  • Genetic Testing: Exome and Genome Sequencing for the Diagnosis of Genetic Disorders Medical Policy
  • Genetic Testing: Ophthalmology Medical Policy
  • Genetic Testing: Gastroenterology Medical Policy
  • Genetic Testing: General Approach to Laboratory Testing Medical Policy
  • Genetic Testing: Otolaryngology Medical Policy
  • Genetic Testing: Hematology Medical Policy
  • Genetic Testing Oncology: Hereditary Cancer Medical Policy
  • Genetic Testing: Immunology and Rheumatology Medical Policy
  • Genetic Testing: Nephrology Medical Policy
  • Genetic Testing: Respiratory Medical Policy
  • Genetic Testing: Nutrition and Metabolism Medical Policy
  • Genetic Testing: Multisystem Genetic Conditions Medical Policy
  • Genetic Testing: Toxicology and Pharmacogenomics Medical Policy
  • Genetic Testing Reproductive: Carrier Screening Medical Policy
  • Genetic Testing Reproductive: Prenatal Screening Medical Policy
  • Genetic Testing Reproductive: Prenatal Diagnosis Medical Policy
  • Genetic Testing: Orthopedics Medical Policy
  • Genetic Testing Oncology: Algorithmic Assays Medical Policy
  • Genetic Testing Oncology: Cancer Screening and Surveillance Medical Policy
  • Genetic Testing Oncology: Circulating Tumor DNA and Circulating Tumor Cell (Liquid Biopsy) – Medical Policy
  • Genetic Testing Oncology: Cytogenetic Testing Medical Policy
  • Genetic Testing Oncology: Solid Tumor Molecular Diagnostics Medical Policy
  • Home Health Care – Medicare Advantage Medical Policy
  • Hyperbaric Oxygen Therapy Medical Policy
  • InFUSE Bone Graft (rhBmp-2) Procedure Medical Policy
  • Lipectomy or Suction-Assisted Lipectomy Medical Policy
  • Obesity Management, Surgical Approaches Medical Policy
  • Oral Appliances and Other Treatments for Obstructive Sleep Apnea
  • Panniculectomy Medical Policy
  • Peripheral Vascular Stents Medical Policy
  • Septoplasty/Rhinoplasty Medical Policy
  • Skin and Tissue Substitutes Medical Policy
  • TMJ Benefit Review Medical Policy
  • Total Disc Arthroplasty Medical Policy
  • Urinary Incontinence Medical Policy

The InterQual® Transparency Tool can be used as part of the utilization management process to provide enhanced clinical detail during the review process. This tool allows for consideration of an individual’s severity of illness, comorbidities and complications during the review process in real-time. To learn more visit Change Healthcare and follow these steps:

1. Create a One Healthcare ID.
2. Once logged in, you can select the subsets from the drop-down menu.
3. Under product, select the appropriate subsets: LOC: Acute Pediatric, CP: Imaging, etc.