| Medical Policy |
| Subject: | Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline | ||
| Policy #: | ADMIN.00006 | Current Effective Date: | 10/12/2011 |
| Status: | Reviewed | Last Review Date: | 08/18/2011 |
| Description/Scope |
The Company reviews services provided, or proposed to be provided, to members in order to determine benefits based on whether the services are medically necessary, not medically necessary, or investigational and not medically necessary. In making such benefit decisions, the Company determines whether such services are in accordance with generally accepted standards of medical practice. In so doing, the Company takes into account credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas, and other relevant factors, as they relate to the member's clinical circumstances.
This document provides a list of resources available to Company Medical Reviewers to use in situations where the Company does not have a Medical Policy or Clinical UM Guideline that addresses the specific service or product for which benefits are requested. If a relevant Medical Policy or Clinical UM Guideline is available, it is to be used as the basis for decision making, and this process is not to be followed. Utilization Management departments will follow their procedures to meet relevant timeframes and notification requirements as appropriate for urgent and non-urgent requests.
NOTE: PLEASE SEE THE DEFINITIONS OF "MEDICALLY NECESSARY" OR "MEDICAL NECESSITY" AND "INVESTIGATIONAL" IN THE COVERED INDIVIDUAL'S PLAN DOCUMENT FOR THE PURPOSE OF MAKING BENEFIT DETERMINATIONS.
PROCESS:
* Note: In determining if there is a relevant Medical Policy or Clinical UM Guideline, the reviewer will not consider procedure code alone. If an 'unlisted' or 'not otherwise classified' code is proposed, the detailed description of service will be the determining factor.
| Rationale |
This document provides a process to be followed when the Company does not have a Medical Policy or Clinical UM Guideline directly applicable to a particular determination of whether a service provided, or proposed to be provided, is medical necessary, not medically necessary, or investigational and not medically necessary. The list of resources included herein is not meant to be exhaustive. Reviewers should use those resources which may be relevant to the decision at hand. They should not feel compelled to use every resource in every case. Reviewers should use more than one resource when more than one resource is relevant to their decision. Reviewers should exercise their professional judgment in selecting appropriate resources and in rendering their determination.
| Definitions |
"Physician Specialty Society" means a United States medical specialty society that represents diplomats certified by a board recognized by the American Board of Medical Specialties.
| References |
Government Agency, Medical Society, and Other Authoritative Publications:
General Certificate(s)
| Specialty Society (+) Indicates Guidelines Publicly Available | Subspecialty Certificate(s) |
Allergy and Immunology
| American Academy of Asthma, Allergy and Immunology (AAAAI) (+)
| None |
Anesthesiology
| American Society of Anesthesiologists (ASA) (+) |
|
Colon and Rectal Surgery
| American Society of Colon & Rectal Surgeons (ASCRS) (+)
| None |
Dermatology
| American Academy of Dermatology (AAD) (+) http://www.aad.org |
|
Emergency Medicine
| American College of Emergency Physicians (ACEP) (+) http://www.acep.org |
|
Family Medicine
| American Academy of Family Practice (AAFP) (+) http://www.aafp.org |
|
Internal Medicine
| American College of Physicians (ACP) (+) http://www.acponline.org |
|
Medical Genetics
| American College of Medical Genetics (ACMG) (+)
|
|
Neurological Surgery
| American Association of Neurological Surgeons (AANS) (+)
| None |
Nuclear Medicine
| American College of Nuclear Medicine (ACNM) (-)
| None |
Obstetrics and Gynecology
| American College of Obstetricians & Gynecologists (ACOG) (-) http://www.acog.org |
|
Ophthalmology
| American Academy of Ophthalmology (AAO) (+)
| None |
Orthopaedic Surgery
| American Academy of Orthopaedic Surgeons (AAOS) (+)
|
|
Otolaryngology
| American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (+) http://www.entnet.org |
|
Pathology
| College of American Pathologists
|
|
| American Society for Clinical Pathology (ASCP) (-) http://www.ascp.org | ||
Pediatrics
| American Academy of Pediatrics (AAP) (+) http://www.aap.org |
|
Physical Medicine and Rehabilitation
| American Academy of Physical Medicine and Rehabilitation (AAPM&R) (+) http://www.aapmr.org |
|
Plastic Surgery
| American Society of Plastic Surgeons (ASPS) (+) http://www.plasticsurgery.org |
|
Preventive Medicine
| American College of Preventive Medicine (AAPM) (+) http://www.acpm.org |
|
American College of Occupational and Environmental Medicine (ACOEM) (+)
| ||
Psychiatry and Neurology
| American Psychiatric Association (APA) (+)
|
|
American Academy of Child & Adolescent Psychiatry (AACAP) (+)
| ||
American Academy of Neurology (AAN) (+)
Child Neurology Society (CNS) (+)
|
| |
Radiology
| American College of Radiology (ACR) (+) NOTE: Do not confuse with American College of Rheumatology |
|
American Society for Therapeutic Radiation and Oncology ASTRO (-)
| ||
Surgery and Vascular Surgery
| American College of Surgeons (ACS) (+) NOTE: Do not confuse with American Cancer Society. |
|
Thoracic Surgery
| Society of Thoracic Surgeons (STS) (+)
| Congenital Cardiac Surgery |
Urology
| American Urological Association (AUA) (+)
|
|
Subspecialty Societies
| Subspecialty Certificate | Specialty Society (+) Indicates Guidelines Publicly Available |
Cardiology
| American College of Cardiology (ACC) (+)
|
Clinical Cardiac Electrophysiology
| Heart Rhythm Society (HRS) (+) (collaborative with ACC)
|
Critical Care Medicine
| Society of Critical Care Medicine (SCCM) (+)
|
Endocrinology, Diabetes and Metabolism
| American Academy of Clinical Endocrinologists AACE (+)
|
Endocrine Society (-)
| |
Gastroenterology
| American Gastroenterological Association (AGA) (+)
|
American College of Gastroenterology (ACG) (-)
| |
Geriatric Medicine
| American Geriatrics Society (AGS) (+)
|
Geriatric Psychiatry
| American Association for Geriatric Psychiatry (AAGP) (+) |
Gynecologic Oncology
| Society of Gynecologic Oncologists (SGO) (+)
|
Hematology
| American Society of Hematology (ASH) (+)
|
Hospice and Palliative Medicine
| American Academy of Hospice and Palliative Medicine (AAHPM) (-)
|
Infectious Disease
| Infectious Disease Society of America (IDSA) (+)
|
Medical Toxicology
| American College of Medical Toxicology (+)
|
Nephrology
| American Society of Nephrology (ASN) (-)
|
| Neuroradiology | American Society of Neuroradiology (ASNR) (-)
|
Oncology
| American Society of Clinical Oncology (ASCO) (+)
|
| Pain Medicine | American Pain Society (APS) (-)
|
Pulmonary Disease
| American College of Chest Physicians (ACCP) (+)
|
| Reproductive Endocrinology/ Infertility | American Society for Reproductive Medicine (ASRM) (+)
|
Rheumatology
| American College of Rheumatology (ACR) (+) NOTE: Do not confuse with American College of Radiology
|
Sleep Medicine
| American Academy of Sleep Medicine (AASM) (+)
|
Sports Medicine
| American Orthopaedic Society for Sports Medicine (AOSSM) (-) http://www.sportsmed.org |
Surgery of the Hand
| American Society for Surgery of the Hand (ASSH) (-)
|
Transplant Hepatology
| American Association for the Study of Liver Diseases (AASLD) (+)
|
American Society of Transplantation (AST) (+)
| |
Undersea and Hyperbaric Medicine
| Undersea and Hyperbaric Medical Society (UHMS) (+)
|
Vascular and Interventional Radiology
| Society of Interventional Radiology (SIR) (+)
|
| Document History |
Status | Date | Action |
| Reviewed | 08/18/2011 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated links. |
| Revised | 08/19/2010 | MPTAC review. Title changed to "Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline." Process, Definition, General Certificate and Subspecialty Certificate information updated. |
| Reviewed | 08/27/2009 | MPTAC review. |
| Reviewed | 08/28/2008 | MPTAC review. Websites reviewed and updated. Addition of the NCCN Drugs & Biologics Compendia™. American College of Sports Medicine removed; replaced with American Orthopaedic Society for Sports Medicine. American Society of Neuroradiology added to specialty society reference. Clinical Immunology Society and Society of Adolescent Medicine removed from specialty society reference. |
| Revised | 02/21/2008 | MPTAC review. |
| Revised | 03/08/2007 | MPTAC review. |
| Revised | 03/26/2006 | MPTAC review. |
| New | 12/01/2005 | MPTAC initial document development. |