| Medical Policy |
| Subject: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline | |
| Document #: ADMIN.00006 | Publish Date: 10/01/2026 |
| Status: Reviewed | Last Review Date: 08/13/2026 |
| 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 Utilization Management (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:
* 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.
Note: For a high-level overview of this document, please see “Summary for Members and Families” below.
| Summary for Members and Families |
This document describes the process by which requests for services are reviewed in the absence of an applicable medical policy or clinical utilization management document. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.
Key Information
This review process is used when there is a request for a service, procedure, or product and there is no applicable company review document that directly addresses the request. The request may be a claim, a request made before care starts, or a service listed with a billing code. A billing code is used for payment and records. Some billing codes are general and do not name one exact service. The reviewer first looks for an applicable company review document that addresses the service. The reviewer looks at the full description of the service, not just the billing code. If a review document applies, the reviewer uses it. If no applicable company review document applies, the reviewer uses trusted medical sources that fit the person’s health needs, the request, and the health plan. A list of such sources are provided below.
The reviewer may use more than one trusted medical source. These sources may include medical studies, government health agency documents, FDA information, medical specialty societies recommendations, and expert feedback from doctors in the relevant medical field. The reviewer uses their medical judgment to choose the sources that best fit the request. The reviewer does not need to use every source for every case. Sometimes there are few or no useful studies or expert recommendations about the service. When this happens, the reviewer considers the lack of information as part of their review. A service that has not been well studied may not have enough evidence to show that it improves health. Additionally, the reviewer should consider the person’s health situation, the rules of their health plan, and other trusted medical information that fits the request. After the review has been completed, the reviewer records the decision and the sources used.
| Rationale |
This document provides a process to be followed when the Company does not have a Medical Policy or Clinical Utilization Management (UM) Guideline directly applicable to a particular determination of whether a service provided, or proposed to be provided, is medically 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: A United States medical specialty society that represents diplomates certified by a board recognized by the American Board of Medical Specialties.
| References |
Government Agency, Medical Society, and Other Authoritative Publications:
*Subspecialties that have been approved, but not yet issued.
| General Certificate(s)
|
Specialty Society
(+) Indicates Guidelines Publicly Available (-) Indicates Guidelines Not Publicly Available |
Subspecialty Certificate(s) |
|
American Academy of Asthma, Allergy and Immunology (AAAAI) (+) http://www.aaaai.org
American College of Allergy, Asthma and Immunology (ACAAI) (+) |
None |
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American Society of Anesthesiologists® (ASA) (+) For additional information visit the ASA website: https://www.asahq.org/
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American Society of Colon and Rectal Surgeons (ASCRS) (+) http://www.fascrs.org
|
None |
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American Academy of Dermatology (AAD) (+) http://www.aad.org
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American College of Emergency Physicians® (ACEP) (+) http://www.acep.org |
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American Academy of Family Practice (AAFP) (+) http://www.aafp.org |
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American College of PhysiciansSM (ACP) (+) http://www.acponline.org |
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American College of Medical Genetics and Genomics (ACMG) (+)
American Board of Medical Genetics and Genomics (ABMGG) (+) |
|
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American Association of Neurological Surgeons (AANS) (+) For additional information visit the AANS website: https://www.aans.org/
|
|
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American College of Nuclear Medicine (ACNM) (-)
|
None |
|
American Congress of Obstetricians and Gynecologists (ACOG) (+) |
|
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American Academy of Ophthalmology (AAO) (+) For additional information visit the AAO website: https://www.aao.org/
|
None |
|
American Academy of Orthopaedic Surgeons (AAOS) (+)
|
|
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American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (+) |
|
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College of American Pathologists
|
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| American Society for Clinical Pathology (ASCP) (-) |
||
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American Academy of Pediatrics (AAP) (+) |
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American Academy of Physical Medicine and Rehabilitation (AAPM&R) (+) |
|
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American Society of Plastic Surgeons® (ASPS) (+) |
|
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American College of Preventive Medicine (AAPM) (+) |
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| American College of Occupational and Environmental Medicine (ACOEM) (+)
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American Psychiatric Association (APA) (+)
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| American Academy of Child & Adolescent Psychiatry (AACAP) (+)
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| American Academy of Neurology® (AAN) (+)
Child Neurology Society (CNS) (-) http://www.childneurologysociety.org
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American College of Radiology (ACR®) (+) NOTE: Do not confuse with American College of Rheumatology
|
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| American Society for Therapeutic Radiation and Oncology ASTRO (+) For additional information visit the ASTRO website:
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American College of Surgeons (ACS) (+) NOTE: Do not confuse with American Cancer Society. |
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Society of Thoracic Surgeons (STS) (+)
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American Urological Association (AUA) (+) For additional information visit the AUA website: https://www.auanet.org/guidelines-and-quality/guidelines
|
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Subspecialty Societies
Subspecialty Certificate |
Specialty Society
(+) Indicates Guidelines Publicly Available (-) Indicates Guidelines Not Publicly Available |
|
| Cardiology
|
American College of Cardiology (ACC) (+)
Society for Cardiovascular Angiography and Interventions (SCAI) (+)
|
|
| Clinical Cardiac Electrophysiology
|
Heart Rhythm SocietySM (HRS) (+) (collaborative with ACC) |
|
| Critical Care Medicine
|
Society of Critical Care Medicine (SCCM) (+) For additional information visit the SCCM website:
|
|
| Endocrinology, Diabetes and Metabolism
|
American Association of Clinical Endocrinologists AACE (+)
|
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| Endocrine Society (+)
|
|
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| Gastroenterology
|
American College of Gastroenterology (ACG) (+)
American Gastroenterological Association (AGA) (+) |
|
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Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) (+)
|
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| Geriatric Medicine
|
American Geriatrics Society (AGS) (+) http://www.americangeriatrics.org
|
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| Geriatric Psychiatry
|
American Association for Geriatric Psychiatry (AAGP) (-)
|
|
| Gynecologic Oncology
|
Society of Gynecologic Oncology (SGO) (+)
|
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| Hematology
|
American Society of Hematology (ASH) (+)
|
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| Hospice and Palliative Medicine
|
American Academy of Hospice and Palliative Medicine (AAHPM) (+)
|
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| Infectious Disease
|
Infectious Disease Society of America (IDSA) (+)
|
|
| Medical Toxicology
|
American College of Medical Toxicology (ACMT) (+)
|
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| Nephrology
|
American Society of Nephrology (ASN) (+)
|
|
| Neuromuscular |
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) (+)
|
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| Neuroradiology |
American Society of Neuroradiology (ASNR) (+)
|
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| Oncology
|
American Society of Clinical Oncology (ASCO®) (+)
|
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| Pain Medicine |
American Chronic Pain Association (ACPA) (+)
American Academy of Pain Medicine (AAPM) (+)
|
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| Pulmonary Disease
|
American College of Chest Physicians® (CHEST) (+)
|
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| Reproductive Endocrinology/Infertility |
American Society for Reproductive Medicine (ASRM) (+)
|
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| Rheumatology
|
American College of Rheumatology (ACR) (+) For additional information visit the ACR website:
NOTE: Do not confuse with American College of Radiology
|
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| Sleep Medicine
|
American Academy of Sleep Medicine (AASM) (+)
|
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| Sports Medicine
|
American Orthopaedic Society for Sports Medicine (AOSSM) (+)
|
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| Surgery of the Hand
|
American Society for Surgery of the Hand (ASSH) (-)
|
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| Transplant Hepatology
|
American Association for the Study of Liver Diseases (AASLD) (+)
|
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| American Society of Transplantation (AST) (+)
|
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| Undersea and Hyperbaric Medicine
|
Undersea and Hyperbaric Medical Society (UHMS) (-)
|
|
| Vascular and Interventional Radiology
|
Society of Interventional Radiology (SIR) (+)
|
|
| Vascular Surgery |
Society for Vascular Surgery (SVS) (+)
|
|
| Document History |
| Status |
Date |
Action |
| Reviewed |
08/13/2026 |
Medical Policy & Technology Assessment Committee (MPTAC) review. Added “Summary for Members and Families” section. Revised Description/Scope, Definitions, and References sections. |
| Reviewed |
08/07/2025 |
MPTAC review. Updated References section. |
| Reviewed |
08/08/2024 |
MPTAC review. Updated References section. |
| Reviewed |
08/10/2023 |
MPTAC review. Updated References section. |
| Reviewed |
08/11/2022 |
MPTAC review. Updated References section. |
| Reviewed |
08/12/2021 |
MPTAC review. Updated References section. Updated Physician Specialty table in the general and subspecialty certificates columns and reformatted table with bullets in place of numeric values. |
| Revised |
08/13/2020 |
MPTAC review. Replaced single quotation marks with double quotation marks, hyphenated the words decision making and placed an asterisk after the comma in the Description/Scope section. Updated References section. Under Physician Specialty Societies’ table, added Neurocritical Care, Micrographic Dermatologic Surgery and added Complex to Pediatric Otolaryngology in the Subspecialty Certificate section of the table. Reformatted general and vascular surgery under the General Certificate section of the table. |
| Reviewed |
08/22/2019 |
MPTAC review. Updated References section. |
| Reviewed |
09/13/2018 |
MPTAC review. Updated References section. |
| Reviewed |
11/02/2017 |
MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Checked functionality of specialty and sub-specialty society hyperlinks and updated any societies who have clinical practice guidelines available publicly. Updated References section. |
| Reviewed |
11/03/2016 |
MPTAC review. Checked functionality of specialty and sub-specialty society hyperlinks and updated any societies who have clinical practice guidelines available publicly. |
| Revised |
11/05/2015 |
MPTAC review. Added the American College of Allergy, Asthma and Immunology. |
| Revised |
08/06/2015 |
MPTAC review. Added Subspecialty certificate for Pain Medicine to Emergency Medicine and Family Medicine. Added to specialty society list: Society for Cardiovascular Angiography and Interventions (SCAI); American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM); Society for Vascular Surgery (SVS). Updated name for American Congress of Obstetricians and Gynecologists. |
| Revised |
08/14/2014 |
MPTAC review. Clarified Process. Added Subspecialty certificates for Emergency Medicine - Anesthesiology Critical Care Medicine. |
| Reviewed |
08/08/2013 |
MPTAC review. Added General Certificates for Radiology - Interventional Radiology and Diagnostic Radiology; Medical Physics. Added Subspecialty certificates for Internal Medicine - Adult Congenital Heart Disease; Pathology - Clinical Informatics. |
| Reviewed |
08/09/2012 |
MPTAC review. Updated Subspecialty Certificate information in Reference section. Updated links. |
| Reviewed |
08/18/2011 |
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. |
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