Clinical Practice Guidelines
Doctors HealthCare Plans complies with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in Traditional Medicare laws. When coverage criteria are not fully established in Medicare statute, regulation, NCD, or LCD; Doctors HealthCare Plans refers to current evidence in widely used treatment guidelines or clinical literature which includes MCG Guidelines, Recognized Compendia as well as other Clinical Practice Resources.
Medicare Coverage Determination Process
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category).
National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS’ own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD). Local coverage determinations (LCDS) are defined in Section 1869(f)(2)(B) of the Social Security Act (the Act). This section states: “For purposes of this section, the term ‘local coverage determination’ means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).” Refer to the Medicare Coverage Database (MCD) Search at: MCD Search (cms.gov).
MCG Care Guidelines
Doctors HealthCare Plan’s uses an industry-leading evidence-based care guidelines which is URAC® Certified for acute and post-acute service authorizations. Informed care leads to the best patient outcomes, avoiding under-use or overuse of medical resources. Evidence-based care guidelines from MCG help providers and health plans drive informed care in their own work and through the conversations that connect them. Refer to the Medical Care Guidelines (MCG) at: Evidence-Based Care Guidance and Solutions
Recognized Compendia List
The off-label, medically accepted indications of Food and Drug Administration-(FDA) approved drugs and biologicals used are identified under the conditions described below. A regimen is a combination of clinically recognized for the treatment of a specific type of disease process. Off-label, medically accepted indications are supported in either one or more of the compendia or in peer-reviewed medical literature. The contractor may maintain its own subscriptions to the listed compendia or peer-reviewed publications to determine the medically accepted indication of drugs or biologicals used off-label treatment regimen. Compendia documentation or peer-reviewed literature supporting off-label use by the treating physician may also be requested of the physician by the contractor. Refer to the following recognized compendia and their websites at:
- American Hospital Formulary Service Drug Information (AHFS-DI): Lexicomp: Evidence-Based Drug Referential Content | Wolters Kluwer
- Micromedex DRUGDEX® Information System: Clinical Decision Support Solutions | Merative
- National Comprehensive Cancer Network® (NCCN®) Drugs and Biologics Compendium: National Comprehensive Cancer Network – Home (nccn.org)
Clinical Practice Resources
Doctors Healthcare Plans, Inc. (“DHCP”) recognizes cultural differences and the influence that race, ethnicity, language and socioeconomic status have on the healthcare experience and health outcomes. We are committed to a direct approach and to provide resources in developing strategies that eliminate health disparities and address gaps in care. Please see the following Resources to Address Cultural Gaps in Care.
Clinical practice guidelines are resources* for Doctor’s HealthCare Plans, Inc. (DHCP) contracted physicians and other DHCP contracted healthcare professionals. DHCP periodically monitors compliance with nationally recognized clinical practice guidelines. DHCP has adopted the following guidelines:
Adult immunizations
https://www.cdc.gov/vaccines-adults/
Asthma care
Global Initiative for Asthma (GINA)
Global Initiative for Asthma (GINA) 2025 reports hub (Strategy Report, Summary Guide, Severe Asthma).
https://ginasthma.org/reports
Atherosclerotic cardiovascular disease
American College of Cardiology
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2019/03/07/16/00/2019-ACC-AHA-Guideline-on-Primary-Prevention-gl-prevention
Back Pain (New for 2020)
Institute for Clinical Systems Improvement
Health Care Guideline: Adult Acute and Subacute Low Back Pain 16th Edition (March 2018)
Breast cancer screening
U.S Preventive Services Task Force; April 30, 2024
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening
Cholesterol treatment
Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication
Chronic obstructive pulmonary disease (COPD)
Chronic Obstructive Pulmonary Disease Screening
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chronic-obstructive-pulmonary-disease-screening
Colorectal Cancer Screening Guideline
American Cancer Society Guideline for Colorectal Cancer Screening
Guideline for Colorectal Cancer Screening
Depression
APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts (2019)
https://www.apa.org/depression-guideline
Diabetes
American Diabetes Association
Standards of Care in Diabetes – 2025
https://diabetesjournals.org/care/issue/48/Supplement_1?utm
Heart failure
2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
https://www.jacc.org/doi/10.1016/j.jacc.2021.12.012
Heart Risk Calculator
American College of Cardiology
Heart Risk Calculator
https://tools.acc.org/ascvd-risk-estimator-plus/?utm
Hypertension
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA
2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Kidney disease
National Kidney Foundation, Kidney Disease Outcomes Quality Initiative
https://www.kidney.org/professionals/kdoqi
Obesity screening in adults
U.S. Preventive Services Task Force
Recommendation: Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions | United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
Opioid Guidelines
Centers for Disease Control
2022 CDC Clinical Practice Guidelines for Prescribing Opioids for Pain
https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/index.html
National Institute on Drug Abuse
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics
https://nida.nih.gov/nidamed-medical-health-professionals/opioid-crisis-pain-management/hhs-guide-clinicians-appropriate-dosage-reduction-or-discontinuation-long-term-opioid
Preventive care
US Dept. of Health and Human Services (HHS)
Preventive Care
https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html
Primary Prevention of Cardiovascular Disease and Stroke
American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines
2019 Guideline on the Primary Prevention of Cardiovascular Disease Guideline Made Simple2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (ahajournals.org)
Sickle Cell Anemia
American Society of Hematology
ASH Clinical Practice Guidelines on Sickle Cell Disease (SCD)
https://www.hematology.org/education/clinicians/guidelines-and-quality-care/clinical-practice-guidelines/sickle-cell-disease-guidelines?utm
Smoking cessation
US Preventive Services Task Force
Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions
Valvular heart disease
AHA/ACC Task Force on Clinical Practice Guidelines
2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease
https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000923?utm
Well-woman routine care
Women’s Preventive Services Institute
2024 Recommendations for Women’s Preventive Health Care: A Well-Woman Chart
https://www.womenspreventivehealth.org/wp-content/uploads/FINAL_2024-Well-Woman-Chart-English.pdf?utm
*Doctor’s HealthCare Plans, Inc. (DHCP) publishes medical guidelines from a number of well-respected national sources. These guidelines may have some differences in recommendations. Information contained in the guidelines is not a substitute for a physician’s or other healthcare professional’s clinical judgment and is not always applicable to an individual. Therefore, the physician or healthcare professional and DHCP member should work in partnership in the decision-making process regarding the member’s treatment. Furthermore, using this information will not guarantee a specific outcome for each member. None of the information in the guidelines is intended to interfere with or prohibit clinical decisions made by a treating physician or other healthcare professional regarding medically available treatment options for DHCP members.
Publication of these guidelines is not a promise or guarantee of coverage. Your DHCP covered members should review their Evidence of Coverage for detailed information.
Links to other websites are provided for your convenience and information only and do not constitute or imply DHCP’s endorsement of these sites, products or services described on these sites, or of any other material contained therein. When you select a link to an external website, you are leaving the DHCP website and are subject to the privacy and security policies of the sponsors of that external website DHCP disclaims responsibility for their content and accuracy.
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Last Updated: 11/06/2025