Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
Annual Review
Prepared By
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options services for Experimental/Investigational Services.
Definitions
Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.
Experimental/Investigational Services – A treatment, procedure, facility, equipment, drug, service, or supply (“intervention”) that has been determined not to be medically effective for the condition being treated.
PROCEDURES
Services meeting ANY of the following criteria are considered experimental/investigational:
· The intervention does not have FDA approval to be marketed for the specified indication(s); or
· Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or
· The intervention is not proven to be safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or
· The intervention does not improve health outcomes; or
· The intervention is not proven to be applicable outside the research setting.
