Medical Policies consist of medical guidelines that are used when making clinical determinations in connection with a member’s coverage under a health plan. The Medical Policies and associated medical guidelines are interpreted and applied at the sole discretion of the health plan fiduciary and may be subject to state or federal laws.
Medical guidelines are based on medical research that provides evidence of scientific merit (or the lack of scientific merit) for particular medical services as related to particular medical conditions. Medical guidelines are based on appropriate and available medical research available at the time they are written. Because of the changing nature of medical science, medical guidelines are reviewed and updated periodically. Accordingly, the information on this Web site is provided for information only and may not reflect a recent policy change or all of the applicable medical guidelines.
The inclusion of a medical guideline on this Web site does not indicate that the referenced service (or supply) is necessarily available to a member. For a determination of the benefits that a particular member is entitled to receive under his or her health plan, such member’s health plan must be reviewed. In the event of a conflict between the Medical Policy and any health plan, the express terms of the health plan will govern. The existence of a medical guideline is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the medical guideline.
Medical guidelines are written to address frequently occurring clinical situations. However, because of the variety of clinical circumstances, some services (or supplies) or conditions addressed in the medical guidelines may be appropriate for additional, individualized review.
Medical Policies ARE NOT medical advice and DO NOT guarantee any results or outcomes.
Medical Policies are covered by copyright and non-permitted use by third parties is strictly prohibited.