Medical Policy Frequently Asked Questions

Medical policies are documents that provide medical necessity and coverage guidelines for all our medical-surgical products.

Medical Policy is the department responsible for the development and maintenance of all medical policies for our medical-surgical contracts. Medical Policy is comprised of individuals who develop and maintain evidence-based coverage guidelines and monitor/assess the medical technology pipeline to anticipate and plan for the evolution of therapies to ensure appropriate benefit adjudication, patient safety, and optimized therapy for our members.

Services, drugs, devices, and supplies are determined to be experimental or investigational based on:

• Advice of the general medical community, including medical consultants, medical journals, and publications,
• Applicable governmental regulations, such as FDA approval,
• Available scientific evidence which doesn't permit conclusions concerning the effect on health outcomes,
• When the service isn't proven to be as safe or effective as alternative treatment or when the service doesn't improve health outcomes, or
• When the service isn't proven to be outside the research setting.

Medical policies address hundreds of issues, such as anesthesia services, consultations, durable medical equipment and supplies, pathology, diagnostic medical services, radiology, nuclear medicine, surgery, cosmetic versus reconstructive surgery, maternity services, therapies, and evaluation and management services. Medical policies also address which services are considered to be experimental/investigational, global, bundled/unbundled, procedures of current questionable usefulness, and services that are considered to be an integral part of a primary service.

Yes. We meet and/or exceed all of NCQA's stringent criteria for our technology evaluations.

Medical policy is intended to further define and enhance a member's benefits. For example, most benefits do not cover experimental/investigational services. Through our technology evaluations, medical policy determines what services are considered to be experimental/investigational.

Medical policy issues are communicated to health care professionals through our monthly publication, Medical Policy Update. If you have questions or comments on new medical policy issues in a particular edition, please complete our Medical Policy Inquiry Request.

Medical Policy Inquiry Request

Yes. Healthcare professionals play an important role in Highmark’s Medical Policy development. Independent healthcare professionals are active in a variety of positions that influence the core of Highmark’s operations. They make up many committees that help to define medical policy, resolve claims disputes, and promote the delivery of quality medical care to Highmark members. We also utilize other resources such as Centers for Medicare and Medicaid Services (CMS) and Blue Cross Blue Shield Association (BCBSA) guidelines, input from various state and national specialty societies, and current published medical literature.