mp-341 - mp-341 - Medical Policies
Homocysteine Testing in the Screening, Diagnosis, and Management of Cardiovascular Disease and Venous Thromboembolic Disease
Policy Number: MP-341
Latest Review Date: December 2020
Policy Grade: A
Effective for dates of service on or after March 17, 2019:
Measurement of plasma levels of homocysteine for the screening, evaluation, and management of patients for cardiovascular disease is considered not medically necessary and investigational.
Measurement of plasma levels of homocysteine for the screening, evaluation, and management of patients with venous thromboembolism or risk of venous thromboembolism is considered not medically necessary and investigational.
Effective for dates of service March 9, 2009 through March 16, 2019:
Measurement of plasma levels of homocysteine for the screening, evaluation, and management of patients for cardiovascular disease is considered not medically necessary.
DESCRIPTION OF PROCEDURE OR SERVICE:
Homocysteine is an amino acid found in the blood which has been evaluated as a potential marker of cardiovascular disease (CVD) in the general population and as a potential risk marker among people with CVD. The association between homocysteine-lowering interventions and risk of CVD has also been examined.
Homocysteine is a sulfur-containing amino acid that is rapidly oxidized in plasma into homocysteine and cysteine-homocysteine disulfide. Measurement of total plasma homocysteine is the sum of homocysteine and its oxidized forms.
Plasma levels of homocysteine have been actively researched as a risk factor for cardiovascular disease (CVD), initially based on the observation that patients with hereditary homocystinuria, an inborn error of metabolism associated with high plasma levels of homocysteine, had a markedly increased risk of CVD. Subsequently, prospective epidemiologic studies were conducted to determine if an elevated plasma level of homocysteine was an independent risk factor for CVD and could be used to improve current risk prediction models. Several case-control studies have also suggested that elevated homocysteine is a risk factor for venous thromboembolism (VTE; pulmonary embolism, deep vein thrombosis).
Interest in homocysteine as a potentially modifiable risk factor has been stimulated by the epidemiologic finding that levels of homocysteine are inversely correlated with levels of folate. This finding has raised the possibility that treatment with folic acid might lower homocysteine levels and, in turn, reduce the risk of cardiovascular disease. Therefore, homocysteine has a potential utility both as a risk predictor and as a target of treatment.
Determination of homocysteine concentration may be offered as a component of a comprehensive cardiovascular risk assessment that may include evaluation of small-density lipoproteins, subclassification of high-density lipoproteins, evaluation of lipoprotein (a), high-sensitivity C-reactive protein, and genotyping of apolipoprotein E. Determination of homocysteine concentration may also be offered as part of the risk assessment for patients at high risk of VTE events or who have experienced idiopathic VTE, recurrent VTE, thrombosis occurring at a young age, or thrombosis at an unusual site.
The most recent literature update was performed through October 16, 2020.
Summary of Evidence
For individuals who are asymptomatic with risk of CVD or individuals with CVD who receive homocysteine testing, the evidence includes observational studies and randomized controlled trials (RCTs) of homocysteine-lowering interventions. Relevant outcomes are are change in disease status and morbid events such as CV events, including myocardial infarction, stroke, and CV death. Evidence from RCTs evaluating homocysteine-lowering interventions does not support the hypothesis that lowering homocysteine levels with folate and/or B vitamins improves CV outcomes. Numerous large RCTs and meta-analyses of these trials have consistently reported that homocysteine-lowering treatment is ineffective in reducing major CV events. A Cochrane systematic review found that homocysteine-lowering treatment reduced the risk of stroke. However, the investigators considered the results weak, and the clinical significance of this reduction is still unknown. Given the large amount of evidence from placebo-controlled randomized trials that homocysteine-lowering interventions do not improve health outcomes, it is unlikely that routine homocysteine testing has the potential to change management that improves health outcomes. The evidence is sufficient to determine that the technology is unlikely to improve the net health outcome.
For individuals who are asymptomatic with risk of venous thromboembolism (VTE) or individuals who have experienced VTE events who receive homocysteine testing, the evidence includes observational studies and RCTs of homocysteine-lowering interventions. Relevant outcomes are change in disease status, and morbid events such as VTE occurrence. Evidence from RCTs evaluating homocysteine-lowering interventions does not support the hypothesis that lowering homocysteine levels with folate and/or B vitamins reduces the risk of VTE. Only a single RCT was designed to test for VTE as a primary outcome. The evidence is insufficient to determine the effects of the technology on health outcomes.
Practice Guidelines and Position Statements
National Institute for Health and Care Excellence
In 2016, The National Institute for Health and Care Excellence updated its guidance on risk assessment and reduction of CVD, including lipid modification. The guidance asserted that full formal risk assessments should use a combination of risk assessment tools as well as informed clinical judgment. Homocysteine testing was not mentioned.
American Heart Association and the American Stroke Association
In 2014, The American Heart Association and the American Stroke Association issued joint guidelines on the primary prevention of stroke. These guidelines were endorsed by the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the Preventive Cardiovascular Nurses Association. The guidelines stated that patients with hyperhomocysteinemia may be treated with B-complex vitamins to prevent ischemic stroke, but that the effectiveness was not clearly established (class IIb; level of evidence B).
American College of Cardiology and American Heart Association
In 2019, the American College of Cardiology (ACC) and the American Heart Association (AHA) issued a joint guideline on the primary prevention of CVD. The use of homocysteine was not mentioned as a marker to guide prevention strategy.
In 2016, the ACC and AHA issued a joint guideline for the management of patients with lower extremity peripheral disease. The guideline recommended against the use of B-complex vitamin supplementation to lower homocysteine, since it did not show benefit in the HOPE-2 trial.
In 2013, the ACC and AHA issued joint guidelines on the assessment of arteriosclerotic cardiovascular risk. These guidelines were endorsed by six medical specialty associations. The guidelines developed multivariable equations to estimate age- and race-specific arteriosclerotic cardiovascular risk. The equations included age, total and high-density cholesterol levels, systolic blood pressure, antihypertensive treatment use, diabetes history, and current smoking status. The use of homocysteine screening for assessing the arteriosclerotic cardiovascular risk was not considered in these guidelines.
National Academy of Clinical Biochemistry
In 2009, The National Academy of Clinical Biochemistry published guidelines on biomarkers for primary prevention of CVD. The Academy concluded that while homocysteine is a modest independent CVD risk factor, homocysteine screening for primary prevention and assessment in healthy individuals was unwarranted.
Agency for Healthcare Research and Quality
In 2016, The Agency for Healthcare Research and Quality issued guidelines for effective quality improvement on preventing hospital-associated venous thromboembolism. The venous thromboembolism prevention protocol recommended a venous thromboembolism risk assessment, a bleeding risk assessment, and clinical decision support on prophylactic choices. Homocysteine testing was not mentioned in these guidelines.
National Institute for Health and Care Excellence
The National Institute for Health and Care Excellence (2018, updated 2019) issued guidance on reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. Homocysteine testing was not mentioned in this guidance.
U.S. Preventive Services Task Force Recommendations
The U.S. Preventive Services Task Force (2018) issued a recommendation on the assessment of CVD risk with nontraditional risk factors. Homocysteine levels were not mentioned in this recommendation.
Homocysteine, homocystine, hyperhomocysteinemia, cardiovascular disease, CVD, venous thromboembolic disease
APPROVED BY GOVERNING BODIES:
Several of the homocysteine test systems have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. FDA product code: LPS. Examples are listed in the table below.
Table. Homocysteine Test Systems
Homocysteine Enzymatic Assay
Diazyme Enzymatic Homocysteine Assay
A/C Automatic Enzymatic Hcy [Homocysteine] Assay
Teco Enzymatic Homocysteine Assay
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.
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- Armitage JM, Bowman L et.al. Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group and Homocysteine Collaborative Group. Effects of homocysteine-lowering with folic acid plus vitamin B12 vs placebo on mortality and major morbidity in myocardial infarction survivors: a randomized trial. JAMA 2010; 303(24-Jan):2486-94.
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Sep 10 2019; 140(11): e596-e646.
- Bazzano LA, Reynolds K, Holder KN, et al. Effect of folic acid supplementation on risk of cardiovascular diseases: a meta-analysis of randomized controlled trials. JAMA 2006; 296(22); 2720-6.
- Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). C-reactive protein as a cardiac risk marker (Special Report). TEC Assessments 2002; Volume 17, Tab 23.
- Bodi V, Sanchis J, Llacer A, et al. Risk stratification in non-ST elevation acute coronary syndromes: Predictive power or troponin1, C-reactive protein, fibrinogen and homocysteine. Int J Cardiol 2005; 98(2):277-82.
- Bonaa KH, Njolstad I, Ueland PM, et al. Homocysteine lowering and cardiovascular events after acute myocardial infarction. NEJM 2006; 354(15):157-88.
- Bostom AG, Selhub J, Jacques PF, et al. Power shortage: clinical trials testing the “homocysteine hypothesis” against a background of folic acid-fortified cereal grain flour. Ann Intern Med 2001; 135(2):133-7.
- Catena C, Colussi G, Nait F, et al. Elevated Homocysteine Levels Are Associated With the Metabolic Syndrome and Cardiovascular Events in Hypertensive Patients. Am J Hypertens. Jul 2015; 28(7):943-950.
- Clarke R, Halsey J, Bennett D et al. Homocysteine and vascular disease: review of published results of the homocysteine-lowering trials. J Inherit Metab Dis 2011; 34(1):83-91.
- Clarke R, Halsey J, Lewington S et al. Effects of lowering homocysteine levels with B vitamins on cardiovascular disease, cancer and cause-specific mortality. Arch Intern Med 2010; 170(18):1622-31.
- den Heijer M, Lewington S, Clarke R. Homocysteine, MTHFR and risk of venous thrombosis: a meta-analysis of published epidemiological studies. J Thromb Haemost. Feb 2005; 3(2): 292-9.
- den Heijer M, Rosendaal FR, Blom HJ, et al. Hyperhomocysteinemia and venous thrombosis: a meta-analysis. Thromb Haemost. Dec 1998; 80(6): 874-7
- den Heijer M, Willems HP, Blom HJ, et al. Homocysteine lowering by B vitamins and the secondary prevention of deep vein thrombosis and pulmonary embolism: A randomized, placebo-controlled, double-blind trial. Blood. Jan 01 2007; 109(1): 139-44.
- Evans RW, Shaten BJ, Hempel JD et al. Homocyst(e)ine and risk of cardiovascular disease in the Multiple Risk Factor Intervention Trial. Arterioscler Thromb Vasc Biol. 1997; 17(10):1947-53.
- Folsom AR, Nieto FJ, McGovern PG, et al. Prospective study of coronary heart disease incidence in relation to fasting total homocysteine, related genetic polymorphisms, and B vitamins: the Atherosclerosis Risk in communities (ARIC) study. Circulation 1998; 98(3):204-10.
- Genest J, Frohlick J, Steiner G. Effect of fenofibrate –mediated increase in plasma homocysteine on the progression of coronary artery disease in type 2 diabetes mellitus. Am J Cardiol 2004; 93(7):277-83.
- Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. Mar 21 2017; 135(12): e726-e779.
- Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Jul 1 2014; 63(25 Pt B):2935-2959.
- Greenland P, Alpert JS, Beller GA et al. American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. 2010 ACCF/AHA guideline for assessment of cardiovascular risk on asymptomatic adults. Circulation 2010; 21: 122(25):e584-636.
- Han L, Wu Q, Wang C, et al. Homocysteine, Ischemic Stroke, and Coronary Heart Disease in Hypertensive Patients: A Population-Based, Prospective Cohort Study. Stroke. Jul 2015; 46(7):1777-1786.
- Homocysteine Studies Collaboration. Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis. JAMA. Oct 2002; 288(16): 2015-22.
- Huang T, Chen Y, Yang B et al. Meta-analysis of B vitamin supplementation on plasma homocysteine, cardiovascular and all-cause mortality. Clin Nutr 2012; 31(4):448-54.
- Jacques PF, Selhub J, Bostom AG, et al. The effect of folic acid fortification on plasma folate and total homocysteine concentrations. NEJM 1999; 3409(19):1449-54.
- Kaul S, Zadeh AA, Shah PK. Homocysteine hypothesis for atherothrombotic cardiovascular disease: non-validated. J Am Coll Cardiol 2006; 48(5):94-23.
- Knekt P, Reunanen A, Alfthan G, et al. Hyperhomocysteinemia: a risk factor or consequence of coronary heart disease. Arch Intern Med 2001; 16(13):1589-94.
- Liem A, Reynierse-Buitenwerf GH, Zwinderman AH, et al. Secondary prevention with folic acid; effects on clinical outcomes. J Am Coll Cardiol 2003; 41(120:2105-13.
- Liu Y, Tian T, Zhang H, et al. The effect of homocysteine-lowering therapy with folic acid on flow-mediated vasodilation in patients with coronary artery disease: a meta-analysis of randomized controlled trials. Atherosclerosis. Jul 2014; 235(1):31-35.
- Lonn E, Yusuf S, Arnold MJ, et al. Homocysteine lowering with folic acid and B vitamins in vascular disease. NEJM 2006; 354(15):1567-77.
- Manilnow MR, Boston AG, Krauss RM. Homocyst(e)ine, diet and cardiovascular diseases: a statement for healthcare professionals from the Nutrition Committee, American Heart Association. Circulation 1999; 99(1):178-92.
- Marti-Carvajal AJ, Sola I, Lathyris D. Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev. Jan 31 2013, Jan 15 2015, Aug 17 2017.
- Maynard G. Preventing hospital-associated venous thromboembolism: a guide for effective quality improvement. 2nd ed. Rockville, MD: Agency for Healthcare Research and Quality; 2016
- McMahaon JA, Green TJ, Skeaff CM, et al. A controlled trial of homocysteine lowering and cognitive performance. NEJM 2006; 354(26):2764-72.
- Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. Dec 2014; 45(12): 3754-832.
- Morice MC, Serruys PW, Sousa JE, et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. NEJM 2002; 346(23):1773-80.
- Naess IA, Christiansen SC, Romundstad PR, et al. Prospective study of homocysteine and MTHFR 677TT genotype and risk for venous thrombosis in a general population--results from the HUNT 2 study. Br J Haematol. May 2008; 141(4): 529-35.
- National Institute for Health and Care Excellence (NICE). Cardiovascular disease: risk assessment and reduction, including lipid modification [CG181]. 2016; https://www.nice.org.uk/guidance/cg181/chapter/1- Recommendations#identifying-and-assessing-cardiovascular-disease-cvd-risk-2. Accessed October 16, 2020.
- National Institute for Health and Care Excellence (NICE). Venous thromboembolism in over 16s: reducing the risk of hospita-acquired deep vein thrombosis or pulmonary embolism. [NG89]. 2018; https://www.nice.org.uk/guidance/ng89. Accessed October 16, 2020
- Nygard O, Nordehaug JE, Refsum H, et al. Plasma homocysteine levels and mortality in patients with coronary artery disease. NEJM 1997; 337(4):230-6.
- Park CS, Ihm SH, Yoo KD et al. Relation between C-reactive protein, homocysteine levels, fibrinogen and lipoprotein levels and leukocyte and platelet counts, and 10-year risk for cardiovascular disease among healthy adults in the USA. Am J Cardiol 2010; 105(9):1284-88.
- Peng HY, Man CF, Xu J, et al. Elevated homocysteine levels and risk of cardiovascular and all-cause mortality: a meta-analysis of prospective studies. J Zhejiang Univ Sci B. Jan 2015; 16(1):78-86.
- Rasouli ML, Nasir K, Blumenthal RS, et al. Plasma homocysteine predicts progression of atherosclerosis. Atherosclerosos 2005; 181(10:159-65.
- Ray JG. Meta-analysis of hyperhomocysteinemia as a risk factor for venous thromboembolic disease. Arch Intern Med. Oct 26 1998; 158(19): 2101-6.
- Ray JG, Kearon C, Yi Q, et al. Homocysteine-lowering therapy and risk for venous thromboembolism: a randomized trial. Ann Intern Med. Jun 05 2007; 146(11): 761-7.
- Schnyder G, Roffi M, Flammer Y, et al. Effect of homocysteine-lowering therapy with folic acid, vitamin B12 and vitamine B6 on clinical outcome after percutaneous coronary intervention: the Swiss Heart Study: a randomized controlled trial. JAMA 2002; 288(8):973-9.
- Schnyder G, Roffi M, Pin R, et al. Decreased rate of coronary restenosis after lowering of plasma homocysteine levels. NEJM 2001; 345(22):1593-600.
- Sheng L, Wu C, Bai YY, et al. Plasma homocysteine levels are independently associated with alterations of large artery stiffness in men but not in women. J Geriatr Cardiol. May 2015; 12(3):251-256.
- Shi Z, Guan Y, Huo YR, et al. Elevated Total Homocysteine Levels in Acute Ischemic Stroke Are Associated With Long-Term Mortality. Stroke. Sep 2015; 46(9):2419-2425.
- Shoamanesh A, Preis SR, Beiser AS, et al. Circulating biomarkers and incident ischemic stroke in the Framingham Offspring Study. Neurology. Sep 20 2016; 87(12): 1206-11.
- Stubbs PJ, Al-Obaid MK, Conroy RM, et al. Effect of plasma homocysteine concentration on early and late events in patients with acute coronary syndromes. Circulation 2000; 102(6):605-10.
- Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group. Effects of homocysteine-lowering with folic acid plus vitamin B12 vs placebo on mortality and major morbidity in myocardial infarction survivors: a randomized trial. JAMA. 2010; 303(24-Jan):2486-2494.
- Syvanne M, Whittall RA, Turpeinen U et al. Serum homocysteine concentrations, gemfibrozil treatment, and progression of coronary atherosclerosis. Atherosclerosis 2004; 172(2):267-72.
- The Homocysteine Studies collaboration. Homocysteine and risk of ischemic heart disease and stroke; a meta-analysis. JAMA 2002; 288(16); 2015-22.
- Toole JF, Malinow MR, Chambless LE, et al. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial. JAMA 2004; 291(5):565-75.
- U.S. Preventive Services Task Force. Cardiovascular Disease: Risk Assessment Using Nontraditional Risk Factors. 2018; https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cardiovascular-disease-screening-using-nontraditional-risk-assessment. Accessed October 16, 2020.
- U.S. Preventive Services Task Force. Using nontraditional risk factors in coronary heart disease risk assessment: U.S. Preventive Services Task Force recommendation statement. 2009. Available online at: www.guideline.gov.
- van Dijk SC, Enneman AW, Swart KM, et al. Effects of 2-year vitamin B12 and folic acid supplementation in hyperhomocysteinemic elderly on arterial stiffness and cardiovascular outcomes within the B-PROOF trial. J Hypertens. Sep 2015; 33(9):1897-1906; discussion 1906.
- Veeranna V, Zalawadiya SK, Niraj A et al. Homocysteine and reclassification of cardiovascular disease risk. J Am Coll Cardiol 2011; 58(10):1025-33.
- Vermeulen EG, Stehouwer CD, Twisk JW, et al. Effect of homocysteine-lowering treatment with folic acid plus vitamin B6 on progression of subclinical atherosclerosis: a randomized, placebo-controlled trial. Lancet 2000; 355(9203):517-22.
- Wald DS, Wald NJ, Morris JK, et al. Folic acid, homocysteine, and cardiovascular disease: judging causality in the face of inconclusive trial evidence. BMJ 2006; 333(7578):1114-7.
- Wald NJ, Watt HC, Law MR, et al. Homocysteine and ischemic heart disease; results of a prospective study of implications regarding prevention. Arch Intern Med 1998; 158(8):862-7.
- Wang C, Han L, Wu Q, et al. Association between homocysteine and incidence of ischemic stroke in subjects with essential hypertension: A matched case-control study. Clin Exp Hypertens. Nov 2015; 37(7):557-562.
- Wang CY, Chen ZW, Zhang T, et al. Elevated plasma homocysteine level is associated with ischemic stroke in Chinese hypertensive patients. Eur J Intern Med. Jul 2014; 25(6):538-544.
- Woo KS, Chook P, Chan LL, et al. Long-term improvement in homocysteine levels and arterial endothelial functions after 1-year folic acid supplementation. Am J Med 2002; 112(7):535-9.
- Yi X, Zhou Y, Jiang D, et al. Efficacy of folic acid supplementation on endothelial function and plasma homocysteine concentration in coronary artery disease: A meta-analysis of randomized controlled trials. Exp Ther Med. May 2014; 7(5):1100-1110.
- Zhou YH, Tang JY, Wu MJ et al. Effect of folic acid supplementation on cardiovascular outcomes: A systematic review and meta-analysis. PLoS ONE 2011; 6(9):e25142.
Medical Policy Group, January 2009 (2)
Medical Policy Administration Committee, February 2009
Available for comment January 22-March 8, 2009
Medical Policy Group, May 2009 (2)
Medical Policy Administration Committee, June 2009
Medical Policy Group, April 2011 (1): Update to Description, Key Points and References
Medical Policy Group, November 2012 (1): 2012 Updates to Key Points and
References. Policy statement remains unchanged
Medical Policy Group, February 2014 (1): Update to Key Points and References; no change to policy statement
Medical Policy Panel, April 2014
Medical Policy Group, April 2014 (1): Policy updated with literature review through
February 2014; no references added; no change to policy statement
Medical Policy Panel, April 2015
Medical Policy Group, May 2015 (3): 2015 Updates to Key Points & References; no change in policy statement.
Medical Policy Panel, December 2015
Medical Policy Group, January 2016 (3): 2015 Updates to Key Points & References; no change in policy statement
Medical Policy Panel, December 2018
Medical Policy Group, January 2019 (9): Annual updates to Key Points & Description. Scope of review broadened to include venous thromboembolism. Investigational policy statement added for homocysteine measurement in the evaluation of venous thromboembolism disease. Title of policy updated to include addition “and Venous Thromboembolic Disease”.
Available for comment January 30, 2019 through March 16, 2019
Medical Policy Administration Committee, February 2019
Medical Policy Panel, December 2019
Medical Policy Group, December 2019 (9): 2019 Updates to Key Points, Description. Added key words: cardiovascular disease, CVD, venous thromboembolic disease. No change to intent of policy statement.
Medical Policy Panel, December 2020
Medical Policy Group, December 2020 (9): 2020 Updates to Key Points, Description, References. No change to policy statement.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect 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.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.