AS THESE CRITERIA MAY NOT BE THE CRITERIA USED IN THE DEFINITION OF INVESTIGATIONAL WITHIN THE COVERED INDIVIDUAL'S PLAN DOCUMENT, THESE CRITERIA ARE NOT TO BE USED FOR BENEFIT DETERMINATIONS FOR A COVERED INDIVIDUAL. (SEE COVERED INDIVIDUAL'S BENEFIT PLAN FOR SPECIFIC CONTRACT LANGUAGE.)

"Investigational" means that the procedure, treatment, supply, device, equipment, facility or drug (all services) does not meet the WellPoint Technology Evaluation Criteria because it does not meet one or more of the following criteria:

• have final approval from the appropriate government regulatory body; or
• have the credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community which permits reasonable conclusions concerning the effect of the procedure, treatment, supply, device, equipment, facility or drug (all services) on health outcomes; or
• be proven materially to improve the net health outcome; or
• be as beneficial as any established alternative; or
• show improvement outside the investigational settings.

In addition to the above criteria, the Medical Policy & Technology Assessment Committee (MPTAC) will consider recommendations of national physician specialty societies, nationally recognized professional healthcare organizations and public health agencies, and in its sole discretion, may consider other relevant factors, including information from the practicing community.

"Investigational" Criteria
Investigational