Medical Policies

This section contains Medical Policies approved by Wellmark Blue Cross and Blue Shield of Iowa and Wellmark Blue Cross and Blue Shield of South Dakota. Medical policy determines if, and under what circumstances, medical services may be eligible for coverage. Policies include detailed clinical criteria that are applied only after a member's contractual benefit has been determined. Wellmark may establish medical policies for procedures, devices or drugs.

Medical Policies are based on data from peer-reviewed scientific literature, criteria developed by specialty societies and guidelines adopted by other health care organizations. Medical policies are based on research that provides evidence of scientific merit for a particular medical technology. Determinations with respect to technologies are made using technology evaluation criteria. The criteria are as follows:

• The technology must have final approval from the appropriate governmental regulatory bodies
• The scientific evidence must permit conclusions concerning the effect of technology on health outcomes
• The technology must improve the net health outcome
• The technology must be as beneficial as any established alternatives
• The improvement must be obtainable outside the investigational settings

Medical technology is constantly evolving and these Medical Policies are subject to change without notice, except as required by law. Additional Medical Policies may be developed from time to time and some may be withdrawn from use. The definition of Active Policy; No Longer Scheduled For Routine Literature Review: This means a policy will be used to process claims but it will not be subject to the routine annual literature review. If there are new developments that warrant a more rigorous review, please submit your comments through the provider clinical feedback form.

Network providers are involved in the Medical Policy process. A number of network providers regularly sit on Wellmark's Medical Policy Advisory Council (MPAC). As needed for complex or controversial issues, we invite local physician experts to advise MPAC. MPAC may direct further consultation with external technology assessment services and databases, consultation with local experts, and further investigation into scientific literature and other sources. While scientific evidence-based methodology guides decisions, consideration is given to the social and economic impact upon patients and providers.

Feedback

Input from clinicians influences how we make coverage decisions. Whether you have a general comment or specific information you would like to share regarding medical policies, we want to hear from you. Submit your comments through the provider clinical feedback form.

Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

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