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Clinical Determinations and Indications–Information for Providers

VA publishes Clinical Determinations and Indications (CDIs) that outline clinical criteria and parameters for services and procedures that Veterans may receive in the community. CDIs were previously known as Community Care Medical Policies.

NOTE: While CDIs are intended for community providers, VA providers and staff should also use them as a clinical review tool when determining clinical appropriateness.

Referencing CDIs before providing care will increase the speed at which VA processes requests for services from community providers. It also helps ensure the care being recommended meets VA clinical criteria.

Please note that CDIs will not affect provider reimbursement for care at this time. Payment continues to be governed by existing contracts. Check this page regularly to ensure you have the most current CDI.

To access the library of published CDIs, please read and accept the end user agreement below.

End User Agreement to Access Library of Clinical Determinations and Indications

By clicking “I Accept,” I acknowledge and accept the following:

  • Clinical Determinations and Indications are intended to be reference material for non-VA providers and do not guarantee benefits or constitute medical advice. The treating clinician is solely responsible for provision of medical advice and the treatment of the Veteran. Veterans should review CDIs with their local Veterans Affairs Medical Center (VAMC) to discuss coverage determinations.
  • Clinical Determinations and Indications express VA’s determination of whether certain services or treatments are medically necessary and appropriate. The CDIs are in accordance with 38 C.F.R. §17.38 (b) and (c)(3) based on the comprehensive analysis of current evidence-based resources, which may include the following:
    • Peer-reviewed literature from academic medical journals
    • Clinical practice guidelines from national health professional organizations
    • Guidance from VA and Department of Defense (DoD) resources
    • Guidance from U.S. regulatory entities (Food and Drug Administration, Centers for Medicare and Medicaid Services, federal and state mandates)
    • Evidence-based guidelines of public health and health research agencies
    • Clinical expertise and judgment of VA physicians from the national program offices
  • The VA medical benefits package is not a health insurance plan. It is a benefit grounded in statute and regulation.

Please indicate your agreement and acceptance by selecting the button labeled "I Accept" below.

I Accept I DO NOT Accept

Preliminary Determinations

The list below reflects preliminary coverage determinations for services or procedures that do not have a CDI.

Preliminary Coverage Determinations
Service Line Care/Servce CPT Code Determination
Surgery Thread Carpal Tunnel Release 25999, 64999 Not covered

Frequently Asked Questions

How do Clinical Determinations and Indications differ from Standardized Episodes of Care?

VA Clinical Determinations and Indications provide guidance about specific treatments, services or devices. They also outline the clinical criteria requirements to determine the medical necessity of a treatment or service. In contrast, a Standardized Episode of Care (SEOC) allows VA to clearly request and deliver bundled health care services as part of a treatment plan within a specific period of time. VA issues SEOCs to community providers to clarify allowable services and procedures within a particular referral. You can view the SEOC billing code information on the Precertification Requirements page.

Precertification Requirements

What if I cannot find the appropriate clinical determination and indication, or a device or procedure is not covered by an existing CDI?

VA is in the process of creating more Clinical Determinations and Indications for community providers. If one is not available, please contact the Veteran’s local VA facility to obtain the clinical criteria for recommended care. If the clinical criteria still cannot be identified, submit your question pertaining to a published Clinical Determination and Indication by completing VA Form 10-322, Community Care Medical Coverage Policy Question Submission Form, and emailing it to the IVC Medical Policy Unit at the email below.

How often does VA publish new or updated clinical determinations and indications?

VA reviews and updates the Clinical Determinations and Indications regularly. Please check this webpage for an updated version periodically. For the latest updates on VA community care, please sign up for the Provider Advisor newsletter.

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Contacts

VHA16IVCMedicalCoveragePolicy@va.gov
Questions? Email a completed VA Form 10‑322 to the IVC Medical Policy Unit.

Please note:

  • This email is only a means to submit a completed VA Form 10‑322.
  • This email is NOT to be used to submit Request for Service (RFS), instructions for the RFS process are on the Care Coordination page.

Additional Information

Care CoordinationPrecertification RequirementsCommunity Care Network–Providers