Blue Cross covers medically necessary care

As a reminder, Blue Cross Blue Shield of Michigan covers medically necessary care, defined in the Blue Cross Blue Shield of Michigan Commercial Provider Manual as procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms.

Medically necessary care must also be:

• In accordance with generally accepted standards of medical practice
• Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease
• Not primarily for the convenience of the patient, physician or other health care provider
• Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease

The provider manual further states that these standards are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, the views of medical practitioners working in relevant clinical areas, and other factors.

Physical medicine services must be:

• Medically necessary and appropriate for the patient’s acute diagnosis due to recent illness, injury or distinct aggravation of a condition or surgery
• Given for a condition that can be significantly improved in a reasonable and generally predictable period of time
• Documented in the patient’s medical record

Providers with questions should call Provider Services at 313-225-9000 or 1-800-344-8525. Patients with questions should contact Customer Service at the number on the back of their member ID cards.