Medical Policies

Medical policies are based on the most current medical research available at the time of the policy development. On this site we offer our final medical policies and draft medical policies. The draft policies are available for physician comment for 45 days from the posting date found on the document. We encourage practicing physicians to provide input.

Policies are written to cover a given condition for the majority of people. Each individual's unique clinical circumstances may be considered in light of current scientific literature. Medical policies are based on constantly changing medical science and the Plan reserves the right to review and update our policies as necessary.

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Use the search function above to locate policies by name, number or keyword.
 

Medical Policies by Category

Use the navigation on the left to expand the menu and select specific medical policies by category.

Medical Policies Disclaimer

Benefits are payable in cases of medical necessity and only if services or supplies are not investigational.

Policies are intended to be used for some or all of the following purposes in Blue Cross and Blue Shield's administration of plans: (i) adjudication of claims (including pre-admission certification, pre-determinations and pre-procedure review); (ii) retrospective review of provider claims; (iii) provider audits; (iv) fraud and abuse investigations; and (v) other programs instituted from time to time to determine the appropriateness of payments under plans.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

  1. The technology or treatment must have final approval from the appropriate government regulatory bodies;
  2. The scientific evidence must permit conclusions concerning the effects of the technology on health outcomes;
  3. The technology must improve the net health outcome;
  4. The technology must be as beneficial as any established alternatives;
  5. The improvement must be attainable outside the investigational setting.

 

 

Notice of Nondiscrimination

The Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability or sex.