Medical Policy

 

Subject: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
Document #: ADMIN.00006 Publish Date:    10/17/2018
Status: Reviewed Last Review Date:    09/13/2018

Description/Scope

The Company reviews services provided, or proposed to be provided, to members in order to determine benefits based on whether the services are medically necessary, not medically necessary, or investigational and not medically necessary. In making such benefit decisions, the Company determines whether such services are in accordance with generally accepted standards of medical practice. In so doing, the Company takes into account 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 other relevant factors, as they relate to the member’s clinical circumstances.

This document provides a list of resources available to Company Medical Reviewers to use in situations where the Company does not have a Medical Policy or Clinical UM Guideline that addresses the specific service or product for which benefits are requested. If a relevant Medical Policy or Clinical UM Guideline is available, it is to be used as the basis for decision making, and this process is not to be followed. Utilization Management departments will follow their procedures to meet relevant timeframes and notification requirements as appropriate for urgent and non-urgent requests.

PROCESS:

  1. When a claim is submitted with an unlisted code, a request for predetermination is made, or a service, procedure, or product is otherwise subject to review, the Company reviewer will determine, based on the description of service*, if there is a relevant Medical Policy or Clinical UM Guideline pertaining to the procedure, service or product. If a relevant Medical Policy or Clinical UM Guideline is available, it is to be used as the basis for decision making, and this process is not to be followed.
  2. If no Medical Policy or Clinical UM Guideline is directly applicable to the decision to be made, reviewers will use their discretion and professional judgment to select resources from the list below or as otherwise identified by the reviewer, which may be appropriate to be referenced for the requested services based on the clinical circumstances of the member. If there is minimal or no relevant peer reviewed literature and/or none of the identified entities have policies or guidelines, this information will be considered by the reviewer in the context of the member’s benefit plan and apparent lack of peer reviewed evidence related to the coverage for the requested service.
  3. After Medical Reviewers have made their determination, they should document their decision and the resources used in the appropriate medical management system. 

    * Note:  In determining if there is a relevant Medical Policy or Clinical UM Guideline, the reviewer will not consider procedure code alone.  If an 'unlisted' or 'not otherwise classified' code is proposed, the detailed description of service will be the determining factor. 

Rationale

This document provides a process to be followed when the Company does not have a Medical Policy or Clinical UM Guideline directly applicable to a particular determination of whether a service provided, or proposed to be provided, is medically necessary, not medically necessary, or investigational and not medically necessary. The list of resources included herein is not meant to be exhaustive. Reviewers should use those resources which may be relevant to the decision at hand. They should not feel compelled to use every resource in every case. Reviewers should use more than one resource when more than one resource is relevant to their decision. Reviewers should exercise their professional judgment in selecting appropriate resources and in rendering their determination.

Definitions

 

“Physician Specialty Society” means a United States medical specialty society that represents diplomates certified by a board recognized by the American Board of Medical Specialties.

 

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Research and Quality (AHRQ) – Clinical Information. Available at: http://www.ahrq.gov/. Accessed on July 16, 2018.
  2. American Board of Medical Specialties. Specialty and Subspecialty Certificates. 2018. Available at: http://www.abms.org/member-boards/specialty-subspecialty-certificates/. Accessed on August 1, 2018. 
  3. Centers for Disease Control and Prevention (CDC). Available at: http://www.cdc.gov. Accessed on July 16, 2018.
  4. Centers for Medicare & Medicaid Services (CMS). Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on July 16, 2018.
  5. DrugPoints® System (electronic version). Truven Health Analytics, Greenwood Village, CO. Available at: http://www.micromedexsolutions.com. Accessed on July 16, 2018.
  6. Lexicomp® Online. American Hospital Formulary Service® (AHFS®) Online, Hudson, Ohio, Lexi-Comp., Inc. Available at: http://www.wolterskluwercdi.com/lexicomp-online/.Accessed on July 16, 2018.
  7. National Comprehensive Cancer Network®. NCCN Drugs & Biologic Compendium® (electronic version). For additional information visit the NCCN website. https://www.nccn.org/professionals/drug_compendium/content/contents.asp.  Accessed on July 16, 2018.
  8. National Library of Medicine – PUBMED. Available at: http://www.ncbi.nlm.nih.gov/sites/entrez. Accessed on July 16, 2018.
  9. U.S. Food and Drug Administration (FDA). Available at: http://www.fda.gov. Accessed on July 16, 2018.
  10. Physician specialty societies where publicly available:

General Certificate(s)

 

Specialty Society

(+) Indicates Guidelines Publicly Available
(-) Indicates Guidelines Not Publicly Available

Subspecialty Certificate(s)

Allergy and Immunology

 

American Academy of Asthma, Allergy and Immunology (AAAAI) (+)
http://www.aaaai.org

American College of Allergy, Asthma and Immunology (ACAAI) (+)
http://college.acaai.org/about/Pages/default.aspx

None

Anesthesiology

 

American Society of Anesthesiologists®
(ASA) (+)
For additional information visit the ASA website: https://www.asahq.org/

 

  1. Critical Care Medicine
  2. Hospice and Palliative Medicine
  3. Pain Medicine
  4. Pediatric Anesthesiology
  5. Sleep Medicine

Colon and Rectal Surgery

 

American Society of Colon and Rectal Surgeons (ASCRS) (+)
http://www.fascrs.org

None

Dermatology

American Academy of Dermatology (AAD) (+)
http://www.aad.org

  1. Dermatopathology
  2. Pediatric Dermatology

Emergency Medicine

 

American College of Emergency Physicians® (ACEP) (+)
http://www.acep.org

  1. Anesthesiology Critical Care Medicine
  2. Emergency Medical Services
  3. Hospice and Palliative Medicine
  4. Internal Medicine- Critical Care Medicine
  5. Medical Toxicology
  6. Pain Medicine
  7. Pediatric Emergency Medicine
  8. Sports Medicine
  9. Undersea and Hyperbaric Medicine

Family Medicine

 

American Academy of Family Practice (AAFP) (+)
http://www.aafp.org

  1. Adolescent Medicine
  2. Geriatric Medicine
  3. Hospice and Palliative Medicine
  4. Pain Medicine
  5. Sleep Medicine
  6. Sports Medicine

Internal Medicine

 

 

 

American College of PhysiciansSM (ACP) (+)
http://www.acponline.org

  1. Adolescent Medicine
  2. Adult Congenital Heart Disease
  3. Advanced Heart Failure and Transplant Cardiology
  4. Cardiovascular Disease
  5. Clinical Cardiac Electrophysiology
  6. Critical Care Medicine
  7. Endocrinology, Diabetes and Metabolism
  8. Gastroenterology
  9. Geriatric Medicine
  10. Hematology
  11. Hospice and Palliative Medicine
  12. Infectious Disease
  13. Interventional Cardiology
  14. Medical Oncology
  15. Nephrology
  16. Pulmonary Disease
  17. Rheumatology
  18. Sleep Medicine
  19. Sports Medicine
  20. Transplant Hepatology

Medical Genetics

  1. Clinical Biochemical Genetics
  2. Clinical Cytogenetics and Genomics
  3. Clinical Genetics and Genomics (MD)
  4. Clinical Molecular Genetics and Genomics
  5. Laboratory Genetics and Genomics

American College of Medical Genetics (ACMG) (+)
http://www.acmg.net

 

  1. Medical Biochemical Genetics
  2. Molecular Genetic Pathology

Neurological Surgery

 

American Association of Neurological Surgeons (AANS) (+)
For additional information visit the AANS website: https://www.aans.org/

None

Nuclear Medicine

 

American College of Nuclear Medicine (ACNM) (-)
http://www.acnmonline.org

None

Obstetrics and Gynecology

 

American Congress of Obstetricians and Gynecologists (ACOG) (-)
http://www.acog.org

  1. Critical Care Medicine
  2. Female Pelvic Medicine and Reconstructive Surgery
  3. Gynecologic Oncology
  4. Hospice and Palliative Medicine
  5. Maternal and Fetal Medicine
  6. Reproductive Endocrinology/ Infertility

Ophthalmology

 

American Academy of Ophthalmology (AAO) (+)
For additional information visit the AAO website: https://www.aao.org/

None

Orthopaedic Surgery

 

American Academy of Orthopaedic Surgeons (AAOS) (+)
http://www.aaos.org

 

  1. Orthopaedic Sports Medicine
  2. Surgery of the Hand

Otolaryngology

 

American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) (+)
http://www.entnet.org

  1. Neurotology
  2. Pediatric Otolaryngology
  3. Plastic Surgery Within the Head and Neck
  4. Sleep Medicine

Pathology

  1. Pathology- Anatomic/ Pathology-Clinical
  2. Pathology-Anatomic
  3. Pathology-Clinical

 

College of American Pathologists
(CAP) (+) 
http://www.cap.org

 

  1. Blood Banking/Transfusion Medicine
  2. Clinical Informatics
  3. Cytopathology
  4. Dermatopathology
  5. Neuropathology
  6. Pathology – Chemical
  7. Pathology – Forensic
  8. Pathology – Hematology
  9. Pathology – Medical Microbiology
  10. Pathology – Molecular Genetic
  11. Pathology - Pediatric

American Society for Clinical Pathology (ASCP) (-)
http://www.ascp.org

Pediatrics

 

American Academy of Pediatrics (AAP) (+)
http://www.aap.org

  1. Adolescent Medicine
  2. Child Abuse Pediatrics
  3. Developmental-Behavioral Pediatrics
  4. Hospice and Palliative Medicine
  5. Medical Toxicology
  6. Neonatal-Perinatal Medicine
  7. Neurodevelopmental Disabilities
  8. Pediatric Cardiology
  9. Pediatric Critical Care Medicine
  10. Pediatric Emergency Medicine
  11. Pediatric Endocrinology
  12. Pediatric Gastroenterology
  13. Pediatric Hematology-Oncology
  14. Pediatric Hospital Medicine
  15. Pediatric Infectious Diseases
  16. Pediatric Nephrology
  17. Pediatric Pulmonology
  18. Pediatric Rheumatology
  19. Pediatric Transplant Hepatology
  20. Sleep Medicine
  21. Sports Medicine

Physical Medicine and Rehabilitation

 

American Academy of Physical Medicine and Rehabilitation (AAPM&R) (+)
http://www.aapmr.org

  1. Brain Injury Medicine
  2. Hospice and Palliative Medicine
  3. Neuromuscular Medicine
  4. Pain Medicine
  5. Pediatric Rehabilitation Medicine
  6. Spinal Cord Injury Medicine
  7. Sports Medicine

Plastic Surgery

 

American Society of Plastic Surgeons®  (ASPS) (+)
http://www.plasticsurgery.org

  1. Plastic Surgery Within the Head and Neck
  2. Surgery of the Hand

Preventive Medicine

  1. Aerospace Medicine
  2. Occupational Medicine
  3. Public Health and General Preventive Medicine

 

American College of Preventive Medicine (AAPM) (+)
http://www.acpm.org

  1. Addiction Medicine
  2. Clinical Informatics
  3. Medical Toxicology
  4. Undersea and Hyperbaric Medicine

American College of Occupational and Environmental Medicine (ACOEM) (+)
http://www.acoem.org

Psychiatry and Neurology

  1. Psychiatry 
  2. Neurology
  3. Neurology with Special Qualification in Child Neurology

 

American Psychiatric Association (APA) (+)
http://www.psych.org

 

  1. Addiction Psychiatry
  2. Brain Injury Medicine
  3. Child and Adolescent Psychiatry
  4. Clinical Neurophysiology
  5. Consultation-Liaison Psychiatry
  6. Epilepsy
  7. Forensic Psychiatry
  8. Geriatric Psychiatry
  9. Hospice and Palliative Medicine
  10. Neurocritical Care*
  11. Neurodevelopmental Disabilities
  12. Neuromuscular Medicine
  13. Pain Medicine
  14. Sleep Medicine
  15. Vascular Neurology

American Academy of Child & Adolescent Psychiatry (AACAP)  (+)
http://www.aacap.org

 

American Academy of Neurology® (AAN) (+)
http://www.aan.com

Child Neurology Society (CNS) (+)
http://www.childneurologysociety.org

 

Radiology

  1. Diagnostic Medical Physics
  2. Diagnostic Radiology
  3. Interventional Radiology and Diagnostic Radiology
  4. Nuclear Medical Physics
  5. Radiation Oncology
  6. Therapeutic Medical Physics

American College of Radiology (ACR®) (+)
http://www.acr.org
NOTE:  Do not confuse with American College of Rheumatology

  1. Hospice and Palliative Medicine
  2. Neuroradiology
  3. Nuclear Radiology
  4. Pediatric Radiology
  5. Vascular and Interventional Radiology

American Society for Therapeutic Radiation and Oncology ASTRO (+)
For additional information visit the ASTRO website:  
https://www.astro.org/

Surgery and Vascular Surgery

 

American College of Surgeons (ACS) (+) 
http://www.facs.org
NOTE:  Do not confuse with American Cancer Society.   

  1. Complex General Surgical Oncology
  2. Hospice and Palliative Medicine
  3. Pediatric Surgery
  4. Surgery of the Hand
  5. Surgical Critical Care

Thoracic and Cardiac Surgery

Society of Thoracic Surgeons (STS) (+)
http://www.sts.org/

Congenital Cardiac Surgery

Urology

 

American Urological Association (AUA) (+)

For additional information visit the AUA website:
https://www.auanet.org/education/clinical-practice-guidelines.cfm

  1. Female Pelvic Medicine and Reconstructive Surgery
  2. Pediatric Urology

Subspecialty Societies

 

Subspecialty Certificate

Specialty Society

(+) Indicates Guidelines Publicly Available
(-) Indicates Guidelines Not Publicly Available

Cardiology  

 

American College of Cardiology (ACC) (+)
http://www.acc.org

Society for Cardiovascular Angiography and Interventions (SCAI) (+)
http://www.scai.org/Default.aspx

Clinical Cardiac Electrophysiology

 

Heart Rhythm SocietySM (HRS) (+) (collaborative with ACC)
http://www.hrsonline.org/

Critical Care Medicine

 

Society of Critical Care Medicine (SCCM) (+)

For additional information visit the SCCM website:
http://www.sccm.org/Home

Endocrinology, Diabetes and Metabolism

 

American Association of Clinical Endocrinologists AACE (+)
http://www.aace.com

Endocrine Society (-)
http://www.endo-society.org

Gastroenterology

 

American College of Gastroenterology (ACG) (+)
http://www.acg.gi.org

American Gastroenterological Association (AGA) (+)
http://www.gastro.org

Society of American Gastrointestinal and Endoscopic Surgeons SAGES (+)
https://www.sages.org/

Geriatric Medicine

 

American Geriatrics Society (AGS) (+)
http://www.americangeriatrics.org

Geriatric Psychiatry

 

American Association for Geriatric Psychiatry (AAGP) (+)
http://www.aagponline.org/

Gynecologic Oncology

 

Society of Gynecologic Oncology (SGO) (+)
http://www.sgo.org

Hematology

 

American Society of Hematology (ASH) (+)
http://www.hematology.org

Hospice and Palliative Medicine

 

American Academy of Hospice and Palliative Medicine

(AAHPM) (-)
http://www.aahpm.org

Infectious Disease

 

Infectious Disease Society of America (IDSA) (+)
http://www.idsociety.org

Medical Toxicology

 

American College of Medical Toxicology (+)
http://www.acmt.net

Nephrology

 

American Society of Nephrology (ASN) (-)
http://www.asn-online.org

Neuromuscular

American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) (+)
http://www.aanem.org/Home.aspx

Neuroradiology

American Society of Neuroradiology (ASNR) (+)
http://www.asnr.org

Oncology

 

American Society of Clinical Oncology (ASCO®) (+)
http://www.asco.org

Pain Medicine

American Pain Society (APS) (+)  
http://americanpainsociety.org/   

Pulmonary Disease

 

American College of Chest Physicians® (ACCP) (+)
http://www.chestnet.org

Reproductive Endocrinology/Infertility

American Society for Reproductive Medicine (ASRM) (+)
http://www.asrm.org

Rheumatology

 

American College of Rheumatology (ACR) (+) 

For additional information visit the ACR website:
http://www.rheumatology.org/

NOTE:  Do not confuse with American College of Radiology

Sleep Medicine

 

American Academy of Sleep Medicine (AASM) (+)
http://www.aasmnet.org

Sports Medicine

 

American Orthopaedic Society for Sports Medicine (AOSSM) (-)
http://www.sportsmed.org

Surgery of the Hand

 

American Society for Surgery of the Hand (ASSH) (-)
https://www.assh.org/  

Transplant Hepatology

 

American Association for the Study of Liver Diseases (AASLD) (+)
http://www.aasld.org

American Society of Transplantation (AST) (+)
https://www.myast.org/

Undersea and Hyperbaric Medicine

 

Undersea and Hyperbaric Medical Society (UHMS) (-)
https://www.uhms.org/   

Vascular and Interventional Radiology

 

Society of Interventional Radiology (SIR) (+)
http://www.sirweb.org

Vascular Surgery

Society for Vascular Surgery (SVS) (+)
www.vascularweb.org/

 

 
Document History

Status

Date

Action

Reviewed

09/13/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.

Reviewed

11/02/2017

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Checked functionality of specialty and sub-specialty society hyperlinks and updated any societies who have clinical practice guidelines available publicly. Updated References section.

Reviewed

11/03/2016

MPTAC review. Checked functionality of specialty and sub-specialty society hyperlinks and updated any societies who have clinical practice guidelines available publicly.

Revised

11/05/2015

MPTAC review. Added the American College of Allergy, Asthma and Immunology.

Revised

08/06/2015

MPTAC review.  Added Subspecialty certificate for Pain Medicine to Emergency Medicine and Family Medicine.  Added to specialty society list: Society for Cardiovascular Angiography and Interventions (SCAI); American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM); Society for Vascular Surgery (SVS). Updated name for American Congress of Obstetricians and Gynecologists.

Revised

08/14/2014

MPTAC review. Clarified Process.  Added Subspecialty certificates for Emergency Medicine - Anesthesiology Critical Care Medicine.

Reviewed

08/08/2013

MPTAC review. Added General Certificates for Radiology – Interventional Radiology and Diagnostic Radiology; Medical Physics. Added Subspecialty certificates for Internal Medicine – Adult Congenital Heart Disease; Pathology – Clinical Informatics.

Reviewed

08/09/2012

MPTAC review. Updated Subspecialty Certificate information in Reference section. Updated links.

Reviewed

08/18/2011

MPTAC review. Updated links.

Revised

08/19/2010

MPTAC review. Title changed to “Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline.” Process, Definition, General Certificate and Subspecialty Certificate information updated.

Reviewed

08/27/2009

MPTAC review.

Reviewed

08/28/2008

MPTAC review. Websites reviewed and updated. Addition of the NCCN Drugs & Biologics Compendia™. American College of Sports Medicine removed; replaced with American Orthopaedic Society for Sports Medicine. American Society of Neuroradiology added to specialty society reference. Clinical Immunology Society and Society of Adolescent Medicine removed from specialty society reference.

Revised

02/21/2008

MPTAC review.

Revised

03/08/2007

MPTAC review

Revised

03/26/2006

MPTAC review

New

12/01/2005

MPTAC initial document development.