MEDICAL POLICIES

Clinical review criteria to determine medical necessity.

Notice: The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the plan of treatment so we will be able to make a determination on medical necessity and prior approval. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this policy and a member's benefits program, the memberís benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. CMS's Coverage Issues Manual may be referenced on the following Web site: www.cms.hhs.gov/manuals/. (Web site links are accurate at time of publication.) The clinical review criteria expressed here reflects some of the information we consider when determining whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes, and we welcome further relevant information. Each benefit program defines which services are covered.

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