UnitedHealthcare® West Medical Management Guidelines

Please Read the Terms and Conditions Below Carefully.

UnitedHealthcare has developed Medical Management Guidelines to assist us in administering health benefits. These guidelines are provided for informational purposes, and do not constitute medical advice. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.

Our Medical Management Guidelines express our determination of whether a health service (e.g., test, drug, device or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered. The Medical Management Guidelines are also used to determine whether a service falls within a benefit category or is excluded from coverage. They may address such matters as whether services are skilled versus custodial, or reconstructive versus cosmetic.

Benefit coverage for health services is determined by the member specific benefit plan document, such as an Evidence of Coverage or Schedule of Benefits, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these guidelines. The Medical Management Guidelines do not replace an individualized case-by-case review and medical necessity determination for each UnitedHealthcare® West member.

Medical Management Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

Medical Management Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. The MCG™ Care Guidelines are proprietary to MCG™ and are not published on this website. Health Plan coverage is provided by or through UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare Benefits of Texas, Inc., and UnitedHealthcare of Washington, Inc.

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