MEDICAL POLICY ABOUT US

The Blue Cross and Blue Shield of Nebraska (BCBSNE) Medical Policy Committee (MPC) establishes, reviews, updates, and revises a uniform set of medical policies.

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A medical policy is a determination of whether a new or existing technology (treatment, procedure, device, drug, biologic product, diagnostic, etc.) has been scientifically validated to substantially improve health outcomes when applied to patients with a specific disease, illness, injury, or condition. These health outcomes may include, but are not limited to: length of life, quality of life and functional ability. Medical policies are established solely on a scientific, medical basis. Medical policies may also contain elements which address considerations including, but not limited to: quality, frequency, timing and cost effectiveness.

BCBSNE USES FIVE CRITERIA TO DETERMINE WHETHER A TECHNOLOGY HAS BEEN SCIENTIFICALLY VALIDATED.

Any technology which does not meet these criteria is determined to be investigative. These criteria are incorporated into the BCBSNE contract definition of "investigative."

INVESTIGATIVE:

A technology, a drug, biological product, device, diagnostic, treatment or procedure is investigative if it has not been Scientifically Validated pursuant to all of the factors set forth below:

1

Technologies, drugs, biological products, devices and diagnostics must have final approval from the appropriate government regulatory bodies. A drug or biological product must have final approval from the Food and Drug Administration (FDA). A device must have final approval from FDA for those specific indications and methods of use that are being evaluated. FDA or other governmental approval is only one of the factors necessary to determine Scientific Validity.

2

Evidence must permit conclusions concerning the effect of the technology on health outcomes. The evidence should consist of well-designed and well-conducted investigations published in peer-reviewed journals. The quality of the body of studies and the consistency of the results are considered in evaluating the evidence.

The evidence should demonstrate that the technology can measure or alter the physiological changes related to a disease, injury, illness or condition.

In addition there should be evidence based on established medical facts that such measurement or alteration affects the health outcomes.

Opinions and evaluations by national medical associations, consensus panels or other technology evaluation bodies are evaluated according to the scientific quality of the supporting evidence and rationale. Our evidence includes, but is not limited to: Blue Cross and Blue Shield Association Technology Evaluation Center technology evaluations; Hayes Directory of New Medical Technologies' Status; Centers for Medicare and Medicaid Services (CMS) Technology Assessments and United States Food and Drug Administration (FDA) approvals.

3

The technology must improve the net health outcome.

4

The technology must improve the net health outcome as much as or more than established alternatives

5

The improvement must be attainable outside the investigational settings.

BLUE CROSS AND BLUE SHIELD OF NEBRASKA WILL DETERMINE WHETHER A TECHNOLOGY IS INVESTIGATIVE.

The MPC consists of the BCBSNE Medical Director and at least four other individuals selected by the Medical Director, at least three of whom are contracting physicians. The MPC meets four to eight times per year.

After consideration of the evidence regarding a technology, the MPC determines whether the proposed use for the technology is scientifically valid or if it is investigative. Each medical policy is reviewed annually and on an ad hoc basis at the discretion of the MPC chairperson/BCBSNE Vice President, Medical Policy and Medical Director.

MEDICAL POLICY MAINTENANCE

Development, review and updating of medical policies is an ongoing process. The goal is to review all policies annually or more frequently as new information emerges.

"ARCHIVED" policies are no longer scheduled for review but are still considered active policies. Archived policies address services that fit one or more of the following criteria:

  • Are considered standard of care
  • It is unlikely further published literature will change the policy determination
  • There is minimal claims activity

If circumstances change, archived policies can be removed from this category and undergo policy review and potential revision. The message ARCHIVED (date) will appear as a watermark in the background of each policy that has been archived.

"RETIRED" policies are policies no longer scheduled for review and are no longer considered active policies. Retired policies address services that fit one or more of the following criteria:

  • The issue might be better addressed through other mechanisms such as through member contracts
  • The service is considered obsolete
  • The issue is no longer of interest to BCBSNE