Medical policy development and use

Medical policies are used during reviews by our Health Management staff to guide them in determinations of medical necessity and coverage limitations not otherwise specified in the coverage documents. These reviews are generally conducted prior to the service being rendered.

Policy development

The research and formulation of written medical policies supports medically appropriate and cost-effective health care services. The process includes identification of medical services, technology assessment, or coverage issues requiring a new or revised written medical policy. We perform a comprehensive review of the identified issues and our medical policy documentation is developed using the following criteria:

  • Research supports the safety, effectiveness and appropriateness of the service.
  • Medical community in general accepts the effectiveness of the services outside of the investigational settings.
  • Cost/benefit and outcome data are similar to established services.
  • Service has been approved by the appropriate regulatory bodies, if necessary.
  • Coverage document language is consistent with policy.
  • Legal/risk management issues are considered.
  • Financial implications to the plan are reviewed.

Use of medical policies

Commercial: Coverage is subject to the member's specific benefits. Group-specific policy will supersede medical policy when applicable. In the absence of applicable coverage document language, medical policy, or technology review, coverage and medical necessity decisions will be based on medical criteria.

Medicaid: For Medicaid/Healthy Michigan Plan members, coverage is based on medical necessity criteria being met and the appropriate code(s) from the coding section of the medical policy being included on the Michigan Medicaid Fee Schedule. If there's a discrepancy between the medical policy and the Michigan Medicaid Provider Manual, the Michigan Medicaid Provider Manual will govern. For Medical Supplies/DME/Prosthetics and Orthotics, please refer to the Michigan Medicaid Fee Schedule to verify coverage.

Medicare: Coverage is determined by the Centers for Medicare and Medicaid Service (CMS) and/or the Evidence of Coverage (EOC). If a coverage determination hasn't been adopted by CMS, the medical policy applies. See our Medicare Local Coverage Determination criteria information in this Manual.

Review of medical policies

Medical policies are reviewed annually, or more frequently if needed, and approved by the Medical Affairs Committee. New medical policies must also be approved by the Medical Affairs Committee.

Priority Health medical policies can be found under Authorizations > Medical policies.