Policies are written to cover a given condition for the majority of people. Each individual's unique clinical circumstances may be considered in light of current scientific literature. Medical policies are based on constantly changing medical science and Blue Cross reserves the right to review and update our policies as necessary.
Disclaimer: Benefits are payable under Blue Cross and Blue Shield of Alabama health plans only in cases of medical necessity and only if services or supplies are not investigational.
This policy is intended to be used for some or all of the following purposes in Blue Cross and Blue Shield's administration of plans: (i) adjudication of claims (including pre-admission certification, pre-determinations and pre-procedure review), (ii) retrospective review of provider claims, (iii) provider audits, (iv) fraud and abuse investigations, and (v), other programs instituted from time to time to determine the appropriateness of payments under plans.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
- The technology or treatment must have final approval from the appropriate government regulatory bodies;
- The scientific evidence must permit conclusions concerning the effects of the technology on health outcomes;
- The technology must improve the net health outcome;
- The technology must be as beneficial as any established alternatives;
- The improvement must be attainable outside the investigational setting.