Clinical Criteria
for Utilization Management
(UM) Decision-Making
MedCare Partners Health Plan uses applicable Medicare coverage
requirements and clinical criteria when making utilization management
decisions.
Reviewed and approved by: Utilization Management Committee
Effective / Review Date: January 1, 2027
How we make UM decisions
MedCare Partners Health Plan of Texas uses applicable Medicare coverage requirements and clinical criteria when making coverage decisions for medical services, items, and Part B drugs. First, we apply Medicare guidelines to the requested service, item, or Part B drug. If there are no applicable Medicare guidelines, we may use applicable evidence-based clinical criteria and recognized professional guidelines.
Medicare Guidelines:
The following criteria were adopted on 9/25/2026, by the MedCare Partners Health Plan of Texas Utilization Management Committee (comprised solely of physicians) for the purpose of making medical coverage decisions. Other criteria are only used when there is no Medicare guideline that applies to the requested service, item, or Part B drug.
Other Criteria:
These secondary clinical criteria (listed below) were adopted by the MedCare Partners Health Plan of Texas Utilization Management Committee (comprised solely of physicians) on 1/1/2027, to be utilized when there are no Medicare clinical criteria or guidelines available for making medical coverage decisions.
Need a Copy of the Criteria Used for a Decision?
Providers and members may request the specific clinical criteria or guideline used to make utilization management decision.