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Coverage policy: Additional information

What is the Coverage Policy?

Coverage Policy means a statement that sets forth by Health Advantage the medical criteria for coverage under an Arkansas Blue Cross Evidence of Coverage. Some limitations of benefits related to coverage, drug, treatment, service equipment or supply are also outlined in the Coverage Policy.

The existence of an affirmative Coverage Policy does not certify coverage, nor does it override or replace specific coverage language listed in an individual policy or group health plan. While a procedure, technology or drug may be medically necessary, it still may be specifically excluded under the terms of a member's contract or benefit plan, or the use may be an investigational or experimental use of the service and therefore excluded under the experimental or investigational language of the member's benefit contract or plan.

The absence of a specific coverage policy does not indicate that a service is covered. For example, a new device or a new use of an old device may not have been proven safe and effective, but coverage may also have not been previously requested, thereby providing us an opportunity to study the information on the safety and effectiveness of the new use of the device.

A copy of a specific Coverage Policy is available upon request at no cost.

How Are Coverage Decisions Made?

The Health Advantage medical directors, including the regional medical directors, review each Coverage Policy before the policies are implemented. Input is requested from local physicians on each new Coverage Policy. Each existing coverage policy is reviewed for accuracy every two years if the policy restricts coverage of a service, procedure, device or drug.

The following sources of information are consulted for the development of Coverage Policies regarding new or emerging treatments, procedures, devices or drugs:

  • Member's Benefit Certificate or Summary Plan Description: Is the service, procedure, device or drug specifically excluded?;
  • FDA Status: Does the service, device or drug require FDA approval?;
  • Assessment of the effectiveness and safety published by:
    • Agency for Healthcare Research and Quality;
    • American Hospital Formulary Service and/or Clinical Pharmacology and/or NCCN Compendia: Has the drug been recommended for off-label use?;
    • Blue Cross and Blue Shield Association Technology Evaluation Center;
    • Cochrane Library of Systematic Reviews;
    • Formal technology assessment committees of national medical societies;
    • Hayes, Inc. Technology Assessment;
    • National Institutes of Health (NIH);
  • Results of Phase III clinical trials as published in peer-reviewed, mainstream medical journals;
  • Position papers of major medical organizations;
  • Consultation with national medical experts;

A similar process is followed for additional new uses of established procedures, devices or drugs to establish Coverage Policies.

What is a CPT Code?

Current Procedural Terminology (CPT) is a five-digit code for reporting of treatment and diagnostic services performed by physicians. CPT is protected by copyright and trademark owned by the American Medical Association (AMA). Physicians use CPT codes in billing for their services.