Medical Policy

The Office of Medical Policy & Technology Assessment (OMPTA) develops medical policy and clinical utilization management (UM) guidelines (collectively, “Medical Policy”) for the company. The principal component of the process is the review for development of medical necessity and/or investigational and not medically necessary position statements or clinical indications that are objective and based on medical evidence for certain new medical services and/or procedures or for new uses of existing services and/or procedures. The services consisting of medical, surgical, and behavioral health treatments, may include, but are not limited to devices, biologics, specialty pharmaceuticals, gene therapies, and professional health services.

Medical Policies are intended to reflect current scientific data and clinical thinking. While Medical Policy sets forth position statements or clinical indications regarding the medical necessity of individual services and/or procedures, Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage.

The Medical Policy & Technology Assessment Committee (MPTAC) is a multiple disciplinary group including physicians from various medical and behavioral health specialties, clinical practice environments and geographic areas. Voting membership may include:

• External physicians in clinical practices and participating in networks;
• External physicians in academic practices and participating in networks;
• Internal medical directors;
• Chairs of MPTAC Subcommittees.

Non-voting members may include:

• Internal legal counsel;
• Internal medical directors.

MPTAC meets at least three times per year. Agenda topics are identified, researched, updated, collated and distributed to the committee. Input from the medical community is solicited and utilized in developing and updating criteria. In addition, agenda items are identified from, but not limited to: clinical literature, medical operations associates, medical directors, claims operations, external reviews, technology vendors, and other technology assessment entities. Decisions are made by a majority vote of MPTAC voting members present. Majority representation of the voting committee members must be present to constitute a quorum. MPTAC may designate subcommittees when needed, which may include internal or external physicians. The subcommittees shall make recommendations to MPTAC on topics assigned to them by MPTAC.

MPTAC voting members and subcommittee members are required to disclose any potential conflicts of interest. In the event that a MPTAC voting member or subcommittee member discloses a conflict of interest, the associated member will not participate in the vote specific to the proposed relevant Medical Policy.

To reach decisions regarding the medical necessity or investigational status of new or existing services and/or procedures, MPTAC (and its applicable subcommittees) relies on the medical necessity or investigational criteria included in the following policies:

• ADMIN.00004 Medical Necessity Criteria
• ADMIN.00005 Investigational Criteria

In evaluating the medical necessity or investigational status of new or existing services and/or procedures the committee(s) may include, but not limit their consideration to, the following additional information provided to committee members:

• Collated results of electronic literature searches;
• Independent technology evaluation programs and materials published by professional associations, such as:
  • Technology assessment entities;
  • Appropriate government regulatory bodies; and
  • National physician specialty societies and associations.

When reviewing the results of electronic literature searches, the committee may consider study methodology, including but not limited to features such as randomization, blinding, clinically appropriate follow-up periods, and use of validated and objective measurement tools. The committee will also consider whether studies provide credible scientific evidence which permits reasonable conclusions regarding net health outcomes (balance of safety and efficacy) and appropriate comparisons to established alternatives. The literature discussed and included in policy documents should not be construed to represent all of the scientific evidence available on a topic or reviewed in policy development. Publications such as review articles, white papers, case studies, abstracts, and articles not published in medical journals indexed in the National Library of Medicine’s PubMed database are typically not included in policy documents.

The committee(s) may also consider the service/procedure being reviewed as a standard of care in the medical community with supporting documentation.

The committee(s) is also responsible for reviewing and authorizing the use of clinical utilization management guidelines used as the standard Enterprise-wide solution for making determinations of medical necessity which are developed by external entities (for example, MCG care guidelines).

Additionally, for topics deemed to represent a significant change or as otherwise required by law or accreditation, the OMPTA team seeks additional input from selected experienced clinicians. This process allows MPTAC access to the expertise of a wide variety of specialists and subspecialists from across the United States. These individuals are board certified providers who are identified either with the assistance of an appropriate professional medical specialty society, by activity in a participating academic medical center or by participation in a corporate affiliated network. While the various professional medical societies may collaborate in this process through the provision of appropriate reviewers, the input received represents NEITHER an endorsement by the specialty society NOR an official position of the specialty society. MPTAC uses this information in the context of all other information presented from various sources.

Medical Policy may be developed and approved or revised between scheduled MPTAC meetings when there is a need to do so prior to the next scheduled meeting of MPTAC. The research associates of OMPTA will develop the draft Medical Policy and request input from appropriate consultant providers, and if applicable, the relevant subcommittee. An ad-hoc interim MPTAC meeting or vote is scheduled to review and vote on the proposed interim Medical Policy. Policies presented on an interim basis (whether approved, modified or rejected) may be presented for full review and discussion at the next scheduled MPTAC meeting when additional committee input is required (for example, additional clinical input is received).

In the absence of specific Medical Policy, case-by-case individual review is undertaken. A physician designated by the health plan will review the request using the technology assessment criteria and appropriate standards that may include, but are not limited to, any of the following: peer-reviewed literature, other organizations' technology evaluations, Agency for Healthcare Research and Quality (AHRQ), various medical specialty societies' guidelines and assessments, and the clinician's professional judgment. Refer to the following document for additional information: ADMIN.00006 Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline.

All existing Medical Policies are reviewed at least annually through MPTAC to determine continued applicability, appropriateness, and whether there is a need for revision, updates to citations, or other changes.

Medical Policies approved by MPTAC are also communicated throughout the company for inclusion in the benefit plan and for implementation of supporting processes. These communication processes include:

• Attendance of key associates at MPTAC meetings;
• Teleconferences with and written documentation to medical operations associates, medical directors, claims and network relations associates;
• Provision of MPTAC meeting minutes and other relevant documentation to health plan leadership.

Medical Policy decisions affecting our members are reported by our health plans to and reviewed for input by the appropriate physician quality committees, which have the responsibility for reviewing MPTAC activities.

Medical Policy & Technology Assessment Committee
MPTAC
Office of Medical Policy & Technology Assessment
OMPTA
MCG guidelines