Medical Policy


Subject: Medical Policy Formation
Document #: ADMIN.00001 Publish Date:    12/12/2018
Status: Revised Last Review Date:    11/08/2018


The Office of Medical Policy & Technology Assessment (OMPTA) develops medical policy and clinical UM guidelines (collectively, “Medical Policy”) for the company. The principal component of the process is the review for development of medical necessity and/or investigational policy position statements or clinical indications that are objective and based on medical evidence for certain new medical services and/or procedures or for new uses of existing services and/or procedures. The services consisting of medical, surgical, and behavioral health treatments, include, but are not limited to devices, biologics and specialty pharmaceuticals, and professional health services.

Medical Policies are intended to reflect current scientific data and clinical thinking. While Medical Policy sets forth position statements or clinical indications regarding the medical necessity of individual services and/or procedures, 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 Medical Policy & Technology Assessment Committee (MPTAC) is a multiple disciplinary group including physicians from various medical and behavioral health specialties, clinical practice environments and geographic areas. Voting membership may include:

Non-voting members may include:

MPTAC meets at least three times per year. Agenda topics are identified, researched, updated, collated and distributed to the committee. Input from the medical community is solicited and utilized in developing and updating policies. In addition, agenda items are identified from, but not limited to: clinical literature, medical operations associates, medical directors, claims operations, external reviews, technology vendors, and other technology assessment entities. Decisions are made by a majority vote of MPTAC voting members present. Majority representation of the voting committee members must be present to constitute a quorum. MPTAC may designate subcommittees for certain topics, such as hematology/oncology (Hem/Onc) or third party criteria (TPC). Subcommittee membership may be specialty focused (for example, Hem/Onc includes hematologists, medical oncologists and radiation oncologists) or more general (for example, TPC may include various medical and behavioral health specialties) and may include internal or external physicians. The subcommittees shall make recommendations to MPTAC on topics assigned to them by MPTAC.

MPTAC voting members and subcommittee members are required to disclose any potential conflicts of interest. In the event that a MPTAC voting member or subcommittee member discloses a conflict of interest, the associated member will not participate in the vote specific to the proposed relevant Medical Policy.

To reach decisions regarding the medical necessity or investigational status of new or existing services and/or procedures, MPTAC (and its applicable subcommittees) relies on the medical necessity or investigational criteria included in the following policies:

In evaluating the medical necessity or investigational status of new or existing services and/or procedures the committee(s) may include, but not limit their consideration to, the following additional information provided to committee members:

The committee(s) may also consider the service/procedure being reviewed as a standard of care in the medical community with supporting documentation. 

The committee(s) is also responsible for reviewing and authorizing the use of Medical Policy used in making determinations of medical necessity which are developed by external entities (for example, MCG care guidelines or InterQual® criteria).

Additionally, for topics deemed to represent a significant change or as otherwise required by law or accreditation, the medical policy team seeks additional input from selected experienced clinicians. This process allows MPTAC access to the expertise of a wide variety of specialists and subspecialists from across the United States. These individuals are board certified providers who are identified either with the assistance of an appropriate professional medical specialty society, by activity in a participating academic medical center or by participation in a corporate affiliated network. While the various professional medical societies may collaborate in this process through the provision of appropriate reviewers, the input received represents NEITHER an endorsement by the specialty society NOR an official position of the specialty society. MPTAC uses this information in the context of all other information presented from various sources.

Medical Policy may be developed and approved or revised between scheduled MPTAC meetings, when there is a need to do so prior to the next scheduled meeting of MPTAC. The research associates of OMPTA will develop the draft Medical Policy and request input from appropriate consultant providers, and if applicable, the relevant subcommittee. An ad-hoc interim Medical Policy meeting or vote is scheduled to review and vote on the proposed interim Medical Policy. Policies presented on an interim basis (whether approved, modified or rejected) may be presented for full review and discussion at the next scheduled MPTAC meeting when additional committee input is required (for example, additional clinical input is received).

In the absence of specific Medical Policy, case-by-case individual review is undertaken. A physician designated by the health plan will review the request using the technology assessment criteria and appropriate standards that may include, but are not limited to, any of the following: peer-reviewed literature, other organizations' technology evaluations, Agency for Healthcare Research and Quality (AHRQ), various medical specialty societies' guidelines and assessments, and the clinician's professional judgment. Refer to the following policy for additional information: ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline.

All existing Medical Policies are reviewed at least annually through MPTAC to determine continued applicability, appropriateness, and whether there is a need for revision, updates to citations, or other changes.

Medical Policies approved by MPTAC are also communicated throughout the company for inclusion in the benefit plan and for implementation of supporting processes. These communication processes include:

Medical Policy decisions affecting our members are reported by our health plans to and reviewed for input by the appropriate physician quality committees, which have the responsibility for reviewing MPTAC activities.


Medical Policy & Technology Assessment Committee
Office of Medical Policy & Technology Assessment
Specialty pharmaceuticals
Third party criteria

Document History






Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description/Scope section concerning MPTAC membership to include BH specialists. Updated text regarding subspecialty committees, including removal of BH subcommittee. Clarified TPC subcommittee may include BH specialists. Updated Index section.



MPTAC review. Updated Description/Scope concerning MPTAC and subspecialty committee voting membership, clarified that non-voting members may include internal medical directors, added details regarding third party criteria subcommittee, and revised text related to topics brought to interim meetings.



MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Clarification made in the Description/Scope section.



MPTAC review. Minor typographical revisions made to the Description section.



MPTAC review.



MPTAC review. Clarifications to the Description/Scope section.



MPTAC review. Updated Description/Scope concerning MPTAC voting membership and specialist/practitioner involvement in the MPTAC decision-making process.



MPTAC review. Updates to the Description/Scope to include a statement addressing committee(s) responsibility for reviewing and authorizing the use of Medical Policy. Additional format revisions and clarifications throughout the document.



MPTAC review. Clarifications to the Description section with reference to ADMIN.00004 and ADMIN.00005.



MPTAC review. Clarified names of specific departments within the organization. Revised wording throughout the document including the annual review process statement.



MPTAC review. Addition of acronyms for specific organizations including the Office of Medical Policy & Technology Assessment (OMPTA) to the Description/Scope and Index. Revised title for ADMIN.00006 to Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline.



MPTAC review.



MPTAC review. Removed the word experimental from the Description/Scope statement.



MPTAC review. Addition of reference to subcommittees.



MPTAC review. Clarification to wording and removal of procedural information.



MPTAC review. Reference to ADMIN.00006 added; deleted Hayes, Inc. as reference when there is no medical policy or clinical guideline available.



MPTAC review. 

  1. Included statement regarding MPTAC voting member’s requirement to disclose potential conflicts of interest and the reclusion of their associated vote on the relevant medical policy where a conflict of interest has been disclosed.
  2. Modified wording specific to the section beginning “In the absence of specific medical policy…” to align with the Settlement Agreement requirements on Initial Determinations (7.14 a).



MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations Last Review Date Document Number Title
Anthem, Inc.   No prior document  

WellPoint Health Networks, Inc.



Medical Policy and Technology Assessment – Policy Formation