Medical Policy Statement

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Blue Cross® Blue Shield® of Arizona Advantage has developed Medical Policies, to assist us in administering health benefits. These policies are provided for informational purposes, and do not constitute medical advice or medical care. Treating physicians and health care providers are solely responsible for diagnosis, treatment and medical advice. BCBSAZ Advantage members should discuss the information in the medical policies with their treating healthcare professionals.

Our Medical Policies express our determination of whether a health service (e.g., test, drug, device or procedure) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given health service is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies and guidelines.

Medical Policies are developed as needed, are regularly reviewed and updated, and are subject to change. BCBSAZ Advantage will use good faith efforts to provide advance notice of any changes that may have a negative impact on benefits. They represent a portion of the resources used to support BCBSAZ Advantage coverage decision making. Where available, BCBSAZ Advantage will refer to CMS, national and local coverage determinations, local coverage articles, and technical guidelines. They are applied in this hierarchy. BCBSAZ Advantage may use tools developed by third parties, such as the MCGTM Care Guidelines, to assist us in administering health benefits. The MCGTM Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. BCBSAZ Advantage Medical Policies do not contain a prior authorization guidelines. A list of services that are subject to notification/prior authorization requirements can be found on our website.

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H0302_1362_2018 CMS Approved 12/07/2017