Medical policy development and use

Medical policies are used during reviews by our Health Management staff to guide them in determinations of medical necessity and coverage limitations not otherwise specified in the coverage documents. These reviews are generally conducted prior to the service being rendered.

Policy development

The research and formulation of written medical policies supports medically appropriate and cost-effective health care services. The process includes identification of medical services, technology assessment, or coverage issues requiring a new or revised written medical policy. We perform a comprehensive review of the identified issues and our medical policy documentation is developed using the following criteria:

  • Research supports the safety, effectiveness and appropriateness of the service.
  • Medical community in general accepts the effectiveness of the services outside of the investigational settings.
  • Cost/benefit and outcome data are similar to established services.
  • Service has been approved by the appropriate regulatory bodies, if necessary.
  • Coverage document language is consistent with policy.
  • Legal/risk management issues are considered.
  • Financial implications to the plan are reviewed.

Use of medical policies

Commercial: In the absence of applicable coverage document language, medical policy, or technology review, coverage and medical necessity decisions will be based on Medicare coverage criteria.

Medicaid: In the absence of Medical Policy for Medicaid, the State of Michigan Medicaid Provider Manual will be used.

Medicare: See our Medicare Local Coverage Determination criteria information in this Manual.

Review of medical policies

Medical policies are reviewed annually, or more frequently if needed, and approved by the Medical Affairs Committee. New medical policies must also be approved by the Medical Affairs Committee.

Priority Health medical policies can be found under Authorizations > Medical policies.