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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.