Rethinking Traditional Criteria, Part 2:

The Playbook

Traditional screening criteria have been used for so long that users mistakenly identify traditional criteria as a legal prerequisite for Medical Necessity review. Nothing could be further from the truth. CMS makes it quite clear that even though a screening tool should be used as part of the medical review, CMS guidelines clearly state that “CMS does not require a specific criterion set” and then goes on to emphasize that in all cases, “the reviewer shall apply his/her own clinical judgment.”

CMS does not require a certain set of criteria, but they mandate that reviewers use their own clinical judgment as part of the process. CORTEX uniquely...

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