Medicare Advantage Medical Policy Guidelines

At BCBSM and BCN, medical policies follow Medicare Advantage Policy Guidelines to comply with the Centers for Medicare & Medicaid Services (CMS) Policy, National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). The criteria to determine if a service is medically necessary can be accessed on our Medical Policy Router Search page and in additional criteria. When coverage criteria are not fully established by Medicare statutes, NCDs or LCDs, we develop medical necessity guidelines that provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services.

See the Medicare Coverage Database for the most current NCDs, LCDs, Local Coverage Articles (LCAs) and CMS Online Manual System/Transmittals.

Medicare Advantage Policy Guidelines are developed as needed and are subject to a minimum of an annual review, update and approval by a BCBSM/BCN committee. When there is not clear CMS guidance, NCDs or LCDs, an established process exists within the BCBSM/BCN enterprise. Medical policies developed by the Joint Uniform Medical Policy (JUMP) committee structure can be used. The JUMP committee is composed of plan medical directors and practicing community physicians representing primary care and multiple specialties in health care. The extensive review of the medical policies ensures guidelines are based on the highest level of evidence currently available in clinical literature, widely accepted professional guidelines, clinical effectiveness data, community physicians and rigorous new technology assessment reports. The committee makes final recommendations for approval and implementation and reports out to the Utilization Management Committee.

The medical policies are provided as information only for the purpose of transparency of the criteria or medical necessity guidelines used in determining coverage for payment purposes. The existence of the medical policy is not an authorization, certification, explanation of benefits, or a contract for the services, devices, or drugs that is referenced in the medical policy. Medical policies do not constitute medical advice and do not guarantee any results or outcomes. Medical policy is not intended to replace independent medical judgment for treatment of individuals. Treating physicians and health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their physician before making any decisions about medical care.

CMS provides guidance for coverage of certain investigational devices; Medicare guidance related to Investigational Device Exemption (IDE) Studies, including Approved IDE studies can be found at the Investigational Device Exemption studies page.

CMS also discusses Coverage with Evidence Development (CED) criteria for certain NCDs; Description of CED and associated policies applicable to CED may be found at the Coverage with Evidence Development page.

BCBSM and BCN may also adopt criteria developed by third parties (e.g., InterQual, eviCore, etc.) that are held to the same standards for criteria development, review, revision and approval.

For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Evidence of Coverage.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.