Medical Policy



Subject: Investigational Criteria
Document #: ADMIN.00005 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

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 08/03/2017 Medical Policy & Technology Assessment Committee (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