Medical Necessity Criteria & Clinical Practice Guidelines

Medical Necessity Criteria

Banner Medicare Advantage and contracted providers use clinical information sources when making medical necessity determinations. Medical necessity criteria used by Banner Medicare Advantage in clinical decision-making includes, but is not limited to:

  • AHCCCS Medical Policies and Guides (AMPM/ACOM)
  • MCG Care Guidelines
  • National Practice Guidelines and Standards
  • Evidence-based Guidelines
  • Clinical Practice Guidelines (Endorsed by B – UHP)
  • Member-specific information, which includes health history and social determinants.

The criterion used supports clinical decision-making that leads to effective health care practices and improved quality of care to our members. Primary care physicians, specialists, and other health care providers are expected to collaborate with their patient and/or the patient's surrogate to develop and implement treatment plans that are individualized to meet the specific needs of each patient. The criterion does not replace a provider’s clinical judgement, and instead allows the provider to utilize the criteria towards the member’s health care needs. This collaboration allows deviation from the guidelines in unique clinical situations and should be clearly substantiated in the medical record.

Banner Medicare Advantage ensures that our utilization review (UR) team encompasses appropriate criteria, care, services, and benefit coverage when making medical determinations. Banner Medicare Advantage does not encourage providers or staff members to make medical determinations that cause under-utilization of treatment and/or services. Banner Medicare Advantage employees are not provided financial incentives or rewards that causes under-utilization of services and/or treatment. A member’s condition or treatment requirements does not replace the provider’s judgement when and authorization is approved.

A member’s case is forwarded to a Banner Medicare Advantage Medical Director for review and determination when the clinical documentation provided does not meet the criteria. A member’s case may be discussed with our Medical Director upon an attending physician’s request.

  • Banner Medicare Advantage Prime HMO
    (844) 549-1857, TTY 711. Our hours of operation are 8 a.m. to 8 p.m., seven days a week.

  • Banner Medicare Advantage Plus PPO
    (844) 549-1859, TTY 711. Our hours of operation are 8 a.m. to 8 p.m., seven days a week.

  • Banner Medicare Advantage Dual HMO D-SNP
    (877) 874-3930, TTY 711. Our hours of operation are 8 a.m. to 8 p.m., seven days a week.

Medicare requires the appeal process is followed for reconsiderations to an adverse decision once the decision is finalized.  Inpatient level of care denials cannot be reversed by a health plan medical director once a hospital discharge order has been written.  

Please Note:

Claim payments are not guaranteed when an authorization is submitted and approved; it is based on medical necessity review, proper coding, and covered benefits. Payment is dependent on the member’s eligibility at the time of service and/or treatment. To verify a member’s eligibility, please call:

  • Banner Medicare Advantage Prime HMO
    (844) 549-1857, TTY 711. Our hours of operation are 8 a.m. to 8 p.m., seven days a week.

  • Banner Medicare Advantage Plus PPO
    (844) 549-1859, TTY 711. Our hours of operation are 8 a.m. to 8 p.m., seven days a week.

  • Banner Medicare Advantage Dual HMO D-SNP
    (877) 874-3930, TTY 711. Our hours of operation are 8 a.m. to 8 p.m., seven days a week.

Clinical Practice Guidelines

Our health plans adhere to clinical practice guidelines and regularly review our guidance. 

Clinical Practice Guidelines are:

  • Based on valid and reliable clinical evidence or a consensus of health care professionals in that field;
  • Selected with consideration of the needs of our members;
  • Adopted in consultation with our providers;
  • Based on National Practice Standards and;
  • Developed by health care professionals and based on a review of peerreviewed articles published in the United States when national practice guidelines are not available;
  • Recommendations to support clinical decisionmaking.

Primary care physicians, specialists, and other health care providers are expected to collaborate with their patient and/or the patient’s surrogate to develop and implement treatment plans that are individualized to meet the specific needs of each patient. This collaboration allows deviation from the guideline in unique clinical situations and should be clearly substantiated in the medical record.

Our clinical practice guidelines are endorsed or developed with designated, desired outcomes and associated, standardized measures of effectiveness. These guidelines are disseminated to all affected providers and are available to all providers, members, potential members and affiliated allied health professionals upon request.

Additional guideline resources are available through the National Guideline Clearinghouse 

Note: By clicking on any of the links below, you will be leaving our website.


Behavioral Health Guidelines

Behavioral Health Guideline are:

  • Member-Centered
  • Population Outcome Based
  • Research-Based Knowledge
  • Redefined Through Quality Improvement 
  • Compatible with System Policies and Resources

Primary care physicians, specialists and other health care providers are expected to use best practice guidelines in a way that promotes the achievement of desired member outcomes. Best practice guidelines provide research-based knowledge that is intended to work in collaboration with clinical guidelines and service delivery. Best practice guidelines enhance service delivery by ensuring member focused treatment while helping to bridge evidence-based clinical practice research with individualized treatment planning. Our best practice guidelines support in identifying, collecting, evaluating and implementing practices that aid in service delivery that supports member-centered interventions and desired outcomes. The following resources provide additional best practice guidelines. 

  1. American Psychiatric Association: Assessment of Older Adults
  2. AACAP Practice Parameters: Reactive Attachment Disorder and Disinhibited Social Engagement Disorder
  3. Veterans Administration (VA)/Department of Defense (DoD) Clinical Practice Guidelines for Major Depressive Disorder 
  4. American Psychological Association: Guidelines for PTSD
  5. American Psychological Association: Guidelines for Depression for Youth and Adults
  6. American Psychiatric Association: Psychopharmacologic treatment of Patients with Alcohol Use Disorder
  7. American Psychiatric Association: Antipsychotic Use to Treat Agitation or Psychosis in Patients with Dementia