All of our member policies exclude coverage for services and procedures that are experimental/investigational or not medically necessary. Our Corporate Medical Policy Technology Assessment Committee determines, after thorough review of the literature and input from local clinical experts, whether services are experimental or investigational or are medically necessary. Services and procedures that have been reviewed by the Corporate Medical Policy Technology Assessment Committee are listed as Medical Policies.
Our medical directors may consider reimbursement on a case by case basis for experimental/investigational services for life threatening medical illnesses when no other treatment options are available. In considering these exceptions, each individual member's unique clinical circumstances will be considered in light of the current peer-reviewed literature.
For consideration of a member/subscriber's unique clinical circumstance, e.g., for a member with a severe, disabling chronic disease where treatment options are limited, practitioners should send the relevant clinical information (including supporting evidence-based literature) to the Utilization Review Department and indicate the reasons why an exception to the medical policy should be made.
If a procedure or service that is experimental/investigational or not medically necessary is performed without the necessary prior approval of a medical director, the claim for the procedure, as well as for all associated services, will be denied as an uncovered service.
We recognize that new evidence emerges constantly. If you feel a service that is not currently covered by our plans should be considered for coverage, please send supporting material from the peer-reviewed literature to our Chief Medical Officer. He/she will arrange for the issue to be brought to the Technology Assessment Medical Policy Committee for review and consideration.
The Corporate Medical Policy Technology Assessment Committee is comprised of Medical Directors and practicing board-certified physicians from our service area. The committee reaches its decision after careful review of relevant peer reviewed literature and consultation with local clinical experts.
The following five criteria are considered in making a decision:
- The device/service must have received final approval from the appropriate regulatory agency (e.g., FDA), and
- Peer-reviewed literature must demonstrate the impact of the service/procedure on health outcomes, and
- The evidence must show that the technology improves health outcomes, and
- The technology must be at least as effective as established technology, and
- The outcomes must be obtainable outside investigational settings
Members of the Medical Policy Committee share policy drafts and supporting documentation with colleagues in their communities with appropriate expertise. In addition, draft medical policies are posted on our Web sites in "draft" format for 30 days so that any participating physician can provide comments and input. Recommendations are incorporated into a final "draft" and presented to the Medical Policy Committee for review and approval.