Anthem Blue Cross California Clinical Utilization Management (UM) Guideline for Pre-Payment Review Medical Form
Procedure is not covered
Subject:
Description
The Company reviews services provided, or proposed to be provided, to its members to determine benefits coverage based on whether the services are medically necessary or not medically necessary. In making such benefit decisions, the Company determines whether such services are in accordance with generally accepted standards of medical practice, taking 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 guidance to be followed and a list of resources available to Company Medical Reviewers when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a request for review or claim related to the services and codes noted in the table below in connection with a provider who is on pre-payment review. These services and corresponding codes may be modified when additional inappropriate use of services is identified; services and codes may be added to the table accordingly.
After Company Medical Reviewers have made their determination, they should document their decision and the resources used in the appropriate medical management system. Utilization Management departments will follow their standard procedures to meet relevant timeframes and notification requirements as appropriate for urgent and non-urgent requests.
NOTE: PLEASE SEE THE DEFINITIONS OF "MEDICALLY NECESSARY" OR "MEDICAL NECESSITY" AND "INVESTIGATIONAL" IN THE COVERED INDIVIDUAL'S PLAN DOCUMENT FOR THE PURPOSE OF MAKING BENEFIT DETERMINATIONS.
Coding
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
CPT
**Note: In determining if there is a relevant Clinical UM Guideline, the reviewer will not consider procedure code alone. If an 'unlisted' or 'not otherwise classified' code is reported, the detailed description of service will be the determining factor.
Discussion/General Information
As noted above, this document provides guidance to be followed when the Company does not have a Clinical UM Guideline directly applicable to a particular medical necessity determination for a claim related to the above services and codes in connection with a provider who is on pre-payment review. The list of resources included herein is not meant to be exhaustive. Reviewers should use those resources that may be relevant to the decision at hand, but not necessarily 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: 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:
- Agency for Healthcare Research and Quality (AHRQ) – Clinical Information. Available at: http://www.ahrq.gov/. Accessed on March 7, 2023.
- American Board of Medical Specialties. Specialty and Subspecialty Certificates. 2022. Available at: http://www.abms.org/member-boards/specialty-subspecialty-certificates/. Accessed on March 7, 2023.
- Centers for Disease Control and Prevention (CDC). Available at: http://www.cdc.gov. Accessed on March 7, 2023.
- Centers for Medicare & Medicaid Services (CMS). Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on March 7, 2023.
- National Library of Medicine – PUBMED. Available at: http://www.ncbi.nlm.nih.gov/sites/entrez. Accessed on March 7, 2023.
- U.S. Food and Drug Administration (FDA). Available at: http://www.fda.gov. Accessed on March 7, 2023.
- Physician specialty societies where publicly available:
General Certificate(s)
Subspecialty Societies
Subspecialty Certificate
Index
Radiograph
Ultrasound
X-Ray
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
History
Status
Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.
Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
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