The Office of Medical Policy & Technology Assessment develops medical policy for the company. The principal component of the process is the review for medical necessity and experimental/investigational determinations for certain new medical technologies and/or procedures and/or for new uses of existing technologies and/or procedures.  The technologies include devices, biologics and specialty pharmaceuticals, and behavioral health services.

Medical policies are intended to reflect the current scientific data and clinical thinking.  While medical policy will make assessments regarding the medical necessity of individual technologies, etc., Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage.

The Medical Policy and Technology Assessment Committee (MPTAC), is a multiple disciplinary group including physicians from various medical specialties, clinical practice environments and geographic areas.  Voting membership includes:

• external physicians in clinical practices and participating in networks;
• external physicians in academic practices and participating in networks;
• internal medical directors.

Non-voting members include:

• internal legal counsel.

The committee meets at least three times per year.  Agenda topics are identified, researched, updated, collated and distributed to the committee.  Input from the medical community is solicited and utilized in developing policies.  In addition, agenda items are identified from, but not limited to:  clinical literature, medical operations staff, medical directors, claims operations, appeals, technology vendors, and other technology assessment entities.  Decisions are made by a majority vote of the MPTAC voting members present.  Majority representation of the voting committee members must be present to constitute a quorum. The MPTAC may designate subcommittees for certain specialty topics, such as by way of example only, hematology/oncology. The subcommittees may include external physicians that are not members of the MPTAC, but are in clinical or academic practices and are participating in networks. The subcommittees shall make recommendations to the MPTAC on topics assigned to them by the MPTAC. 

MPTAC voting members and subcommittee members are required to disclose any potential conflicts of interest.  In the event that a MPTAC voting member or subcommittee member discloses a conflict of interest, the associated member will not participate in the vote specific to the proposed relevant medical policy.

To reach decisions regarding the medical necessity or investigational status of new or existing technologies and/or procedures, the MPTAC (and its applicable subcommittees) relies on:

• the technology/procedure having final approval from the appropriate regulatory body;
• the technology/procedure being supported by scientific evidence permitting conclusions regarding the effect of the technology on health outcomes;
• the technology/procedure improving net health outcomes;
• the technology/procedure being as beneficial as established alternatives;
• the technology/procedure outcomes/improvements being attainable outside the controlled setting (in practice).

In evaluating the medical necessity or investigational status of new or existing technologies and/or procedures the committee(s) may include, but not limit their consideration, to the following additional information:

• electronic literature searches, which are conducted and collated results are provided to the committee members;
• independent technology evaluation programs and materials published by professional associations, such as:
  • Blue Cross Blue Shield Association;
  • technology assessment entities;
  • appropriate government regulatory bodies AND;
  • various medical specialty societies and associations.

The committee(s) may also consider the technology/procedure being reviewed as a standard of care in the medical community with supporting documentation.

Additionally, for topics deemed to represent a significant change or as otherwise required by law or accreditation, the medical policy team seeks additional input from selected experienced clinicians.  This process allows the MPTAC access to the expertise of a wide variety of specialists and subspecialists from across the country.  These individuals are board certified providers who are identified either with the assistance of an appropriate professional medical specialty society, by activity in a participating academic medical center or by participation in a corporate affiliated network.  While the various professional medical societies may collaborate in this process through the provision of appropriate reviewers, the input received represents NEITHER an endorsement by the specialty society NOR an official position of the specialty society.  The MPTAC uses this information in the context of all other information presented from various sources.

A medical policy may be developed and approved between scheduled MPTAC meetings, if in the opinion of the Vice President for Medical Policy & Technology Assessment or designee, there is an urgent need to establish a new medical policy, or revise an existing policy, prior to the next scheduled meeting of MPTAC.  The research staff of the Office of Medical Policy & Technology Assessment will develop the draft medical policy and request input from appropriate consultant providers, and if applicable, the relevant subcommittee. An ad-hoc interim medical policy meeting or vote is scheduled to review and vote on the proposed interim medical policy. Any policy presented on an interim basis (whether approved, modified or rejected) will be presented for full review and discussion at the next scheduled MPTAC meeting.

In the absence of specific medical policy, case-by-case individual review is undertaken.  A physician designated by the health plan, will review the request using the technology assessment criteria and appropriate standards that may include, but are not limited to, any of the following:  peer-reviewed literature, other organizations' technology evaluations including the Blue Cross Blue Shield Association, Agency for Health Research and Quality (AHRQ), various medical specialty societies' guidelines and assessment and the clinician's professional judgment. (Refer to the following policy for details: ADMIN.00006 Medical Necessity and Investigational/Not Medically Necessary Reviews of Services in the Absence of a Company Applicable Medical Policy or Utilization Management (UM) Clinical Guideline.)

The Vice President for Medical Policy & Technology Assessment or designee performs an annual review of all existing medical policies to determine continued applicability and appropriateness.  He/she will be responsible for identifying which policies will require revision, enhanced updated citations, etc. and re-approval through the MPTAC.

Medical policy determinations of the MPTAC are also communicated throughout the company for inclusion in the benefit package and for implementation of the supporting processes.  These communication processes include:

• attendance of key staff at MPTAC meetings;
• teleconferences with and written documentation to medical operations staff, medical directors, claims and network services staff;
• provision of MPTAC meeting minutes and other relevant documentation to plan leadership.

Medical policy decisions affecting our members are reported by our plans to and reviewed for input by the appropriate physician quality committees, which has the responsibility for reviewing MPTAC activities.

Medical Policy and Technology Assessment Committee
MPTAC