XI-02-004

Medical Policy:

XI-02-004

Topic:

Medical Necessity Criteria for Medical Technologies Which Are Not Addressed by a Specific Medical Policy

Section:

Miscellaneous

Effective Date:

September 30, 2019

Issued Date:

September 27, 2021

Last Revision Date:

September 2019

Annual Review:

September 2021

This policy version was replaced October 3, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

This policy does not apply to the following:

Medical technologies addressed by a specific medical policy utilized by Blue Cross and Blue Shield of Minnesota (Blue Cross).
Medical drugs that are not addressed in a specific policy (see Medical Policy II-173, Accepted Indications for Medical Drugs Which are not Addressed by a Specific Medical Policy).
New FDA-approved medical drugs or medical drug indications on Blue Cross’ Medical Drug Evaluation Process List (see Medical Policy II-174, Evaluation Process for New FDA-Approved Medical Drugs or Medical Drug Indications).

This policy describes criteria by which Blue Cross determines whether a medical technology is being used for a medically accepted indication in the absence of a specific medical policy. These criteria are also used in the development and updating of medical policies.

Definitions:

Generally accepted standards of medical practice: Standards that are based on 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 any other relevant factors.

Medical technology: A device, medical treatment, supplies, or procedure provided to a member by a medical provider for the purpose of preventing, evaluating, diagnosing or treating an Illness, injury, disease or its symptoms.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

A medical technology that a provider (exercising prudent clinical judgment) would provide to a member may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

Not determined to be experimental/investigative per Blue Cross and Blue Shield of Minnesota Medical Policy XI-01 on “Investigative Indications for Medical Technologies Which Are Not Addressed by a Specific Medical Policy”; AND
Used in accordance with generally accepted standards of medical practice; AND
Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the member's Illness, injury or disease; AND
Not primarily for the convenience of the member, or a provider; AND
Not more costly than an alternative medical technology at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that member's Illness, injury or disease, AND
Provided for ONE of the following purposes:
- Help restore or maintain the member’s health; or
- Prevent deterioration of the member’s condition.

Denial Statements

No additional statements.

Links

Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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