Medical Policy
Subject: Investigational Criteria
Document #: ADMIN.00005Publish Date: 07/06/2022
Status: ReviewedLast Review Date: 05/12/2022

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

Definitions

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

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.

Index

“Investigational” Criteria
Investigational

Document History

Status

Date

Action

Reviewed

05/12/2022

Medical Policy & Technology Assessment Committee (MPTAC) review.

Reviewed

05/13/2021

MPTAC review.

Reviewed

05/14/2020

MPTAC review.

Reviewed

06/06/2019

MPTAC review.

Reviewed

07/26/2018

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.”

Reviewed

08/03/2017

MPTAC review.

Reviewed

08/04/2016

MPTAC review.

Reviewed

08/06/2015

MPTAC review.

Revised

08/14/2014

MPTAC review. Clarification to header.

Reviewed

08/08/2013

MPTAC review.

Reviewed

08/09/2012

MPTAC review.

Revised

08/18/2011

MPTAC review. Clarification to header.

Reviewed

11/18/2010

MPTAC review.

Revised

11/19/2009

MPTAC review. Title changed; clarifications made.

Reviewed

11/20/2008

MPTAC review.

Reviewed

11/29/2007

MPTAC review.

Reviewed

12/07/2006

MPTAC review. No change to position.

Revised

12/01/2005

MPTAC review.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

N/A

N/A

Definition: Experimental/Investigational

WellPoint Health Networks, Inc.

09/22/2005

Definitions: i

Definition: Investigational


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 member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

© CPT Only - American Medical Association