Medical Policy

 

Subject: Investigational Criteria
Document #: ADMIN.00005 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

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

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.”

Reviewed

08/03/2017

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