Subject:
Definition of Medical Necessity
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Medical necessity describes a service, supply or procedure (collectively "technology") that a physician or health care professional exercising prudent clinical judgment, would provide to a member for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that is:
- in accordance with the "generally accepted standards of medical practice";
- clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the member's illness, injury or disease;
- not primarily for the convenience of the member or the physician or health care professional; and
- not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the member's illness, injury or disease.
"Generally accepted standards of medical practice" means standards that are based on:
- credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;
- physician and health care provider specialty society recommendations;
- the views of physicians and health care providers practicing in relevant clinical areas; and
- any other relevant factor as determined by the commissioner by regulation.
The fact that a physician or health care professional prescribes, orders, recommends or approves services, supplies, or procedures does not automatically make them medically necessary.
[INFORMATIONAL NOTE: The following guideline serves to define the parameters for determining the components of evidence-based data. It is intended to describe in more depth the concepts inherent in the definition of medical necessity.
I. In determining generally accepted standards of medical practice, the following should be considered:
A. Credible, scientific evidenced-based data.
1. Published in reputable (recognized by clinicians in the practice specialty) peer reviewed publications.
2. Clinical trials or studies that are controlled and randomized when possible.
3. The number of subjects in study represents a statistically significant sample of the population for whom the technology (procedures, device service or drug) is intended.
4. The duration of study or trial including follow-up is of sufficient time to establish safety and clinical efficacy.
5. FDA approval of the technology when it is appropriate.
6. Abstracts, posters or presentations from scientific meetings that are unpublished do not constitute adequate peer-reviewed data.
B. Physician and Health Care Provider specialty society recommendations.
1. Recommendations will be assessed in accordance with supporting evidence-based references.
2. Recommendations will not supersede a member’s contract limitations e.g. exclusion of cosmetic procedures.
C. Views of physicians and health care providers practicing in relevant clinical areas.
1. Consideration will be given to technologies that are widely utilized in clinical practice but not widely studied.
2. The opinions of Independent Medical Reviewers in a specialty-matched field may be sought to contribute to an understanding of the standard of care relating to a particular technology or to establish medical necessity.
3. The clinical orientation of the attending physician will be considered.
4. The type, frequency, extent, site of service, duration and efficacy of a technology will also be considered.
II. Other categories considered.
A. Legislative and regulatory mandates/requirements will take precedence over medical policy and contract language.
B. The technology cannot be primarily for the convenience of the covered person or the health care provider.
C. The most cost effective alternatives that can achieve equivalent therapeutic or diagnostic results will be considered when making a medical necessity determination.]
Policy:
Not applicable to this policy.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Definition of Medical Necessity
Medical Necessity, Definition of
Standards of Medical Practice
Criteria for Establishing the Threshold of Medical Necessity
Medical Necessity, Criteria for Establishing the Threshold of
Threshold of Medical Necessity, Criteria for Establishing the
References:
New Jersey State mandate entitled Health Claims Authorization, Processing and Payment Act (HCAPP). Assembly bill #2848. Effective date: July 12, 2006.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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