The medical coverage policy program includes reviews of technologies for use by medical and behavioral staff in the utilization review process. The coverage policy outlines the medical necessity criteria for coverage for a specific technology, service or device. Coverage Policy criteria are, however, superseded by applicable Federal and State regulation, and by the customer’s Summary Plan Description document. That information is indicated in the Coverage Policy, and appears before any coverage statements, identified by the heading “Instructions For Use”. The coverage policy and new technology development process is consistent with relevant accreditation standards such as those described by URAC and the National Committee for Quality Assurance (NCQA)¹.

A Healthcare Medical Assessment Committee develops and/or reviews and/or approves all medical coverage policies. The committee is composed of physicians and nurses, and includes specialists from assorted disciplines, including behavioral health. Internal subject matter experts are consulted as part of the committee review process. Internal subject matter experts include, but may not be limited to, OBGYNs, oncologists, primary care physicians, internists, surgeons, pulmonologists, cardiologists, neurologists, and psychiatrists. The committee uses principles of evidence-based medicine in its evaluation of clinical literature, in development of its reviews, in its deliberative process, and in preparing published medical coverage policies. Financial considerations do not drive decisions about medical appropriateness.

As part of our review process, FDA approval or clearance, as appropriate, is necessary, but not sufficient, to consider a technology to be proven. If FDA approval or clearance is present, a review of the English language peer reviewed publications, as well as relevant documents prepared by Specialty Societies and evidence-based review centers, such as the Agency for Healthcare Research and Quality is also performed. Levels of evidence are assigned to the publications based upon underlying study characteristics. A research team performs a synthetic assessment of the literature to determine if there is a sufficiently evidence based proven relationship between the intervention and improved health outcomes. This information is presented to the committee who makes a final determination about coverage criteria.

¹ NCQA is a private, non-profit organization dedicated to improving health care quality