Understand Carrier Medical Policy and the Long Denial Process

by Jonnie Massey, AHFI, CPC, CPC-P, CPC-I

When a service is provided to a patient with insurance, it should be paid for, right? That’s what we as patients, providers, or consumers like to believe—if it were only that simple. Generally speaking, when services are provided, one expects compensation. This may not be the case, if the service provided is impacted by medical policy.

Let’s explore medical policy and the process behind developing and reviewing carrier medical policy. Carriers have medical policy that sets coverage guidelines for specific procedures, equipment, and services. To provide for you a better understanding of why service compensation may be denied by carriers, we’ll review the common process used for determining carrier medical policy.

How Medical Policies are Made

Medical policies are determined via an evidence-based review process that may be reviewed in more detail by accessing the individual carrier medical policy development and review process. You can usually review this online or ask for a copy. Please review your carrier’s website or contact them directly for details. Published scientific literature is reviewed against technology evaluation criteria (TEC), all of which must be met for the technology to be considered medically necessary. See the twelve programs the Agency for Healthcare Research and Quality (AHRQ) has designated as evidence-based practice centers.

The TEC are defined as follows:

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

Keep the TEC criteria in mind when submitting data for consideration to a carrier-related to medical policy. Thorough research will be conducted.

Embedded in this evidence-based review process is also a rigorous quality review of published studies following nationally recognized standards for assessing scientific literature. Once the evidence is reviewed, policy drafts are submitted for external review by practicing physicians with expertise in the associated technology fields. Examples may include orthopedic surgeons, primary care physicians, and physical medicine specialists as appropriate to the reviewed policy. It is within this context that the submitted evidence is reviewed in its entirety by the medical policy department.

Things to consider when submitting data to a carrier for a medical policy review or research:

  • Clinical trials: Small-sized clinical trials may not be powerful enough to establish the outcomes’ significance. Considering the prevalence of conditions, are sufficiently powered clinical trials expected?
  • Randomization: Were methods of randomization described in the articles submitted? Few randomization methods can truly be considered randomized (e.g., computer-generated, coin toss). Without a description of the used method, patient selection bias cannot be ruled out.
  • Follow-up period: Is the length of follow-up too short? When determining safety and efficacy of a service, longer-term outcomes are considered a measured primary outcome. For example, the short-term benefits such as a reduction in the use of opiates or better initial range of motion often do not significantly impact the length of the recovery period or the success of a surgery in improving symptoms and functional levels for these patients.
  • Inconsistency: Check for inconsistencies between studies in the measured outcomes and the measurement tools used. This does not permit comparison between most of the available studies.
  • Mixed results: Have there been mixed results in the reviewed studies? Does the submitted material consist of only articles documenting positive outcomes? Would a literature search reveal other studies not supporting these outcomes?

A search of the MEDLINE database may be conducted in addition to the submitted articles. This search may include reviews of random trials. When providing data to carrier-related medical policy, it is beneficial to include information about random trials specific to your service in the data packet you send for review.

Other areas of review may include: a search of the National Guidelines Clearinghouse database and research of the clinical practice guidelines and position statements.

If you feel it’s necessary to send patient or physician letters to support your position, know that letters may be considered anecdotal evidence not meeting the national standards for scientific literature. The benefits reported in anecdotal evidence often are not seen when tested in randomized clinical trials. Patient surveys such as requests for personal experience reports included within submitted patient letters tend to be answered by the patients who have positive experiences. This evidence cannot be considered unbiased. The submitted anecdotal evidence will not be included in the critical appraisal of the published literature.

If there isn’t new data in the published literature, the current medical policy usually remains in place. Medical policy staff continue to monitor the peer-reviewed, published literature on a regular basis. If the literature changes and the five technology assessment criteria are met, the medical policy will be updated.

What Medical Policy Doesn’t Do

Medical policy does not determine the schedule of benefits, but rather, it dictates the process that determines if the services will be paid by the carrier. Keep in mind, medical policy application is subject to state and federal laws, and specific instructions from plan sponsors and self-insured groups.

Medical policy is not medical advice. Questions and concerns about treatment should always be directed to the health care provider. Should a provider or patient use a service or device not allowed by carrier Medical Policy, a waiver clearing indicating the service must be signed prior by the patient before receiving the service.

If you are unclear on the medical policy or you have concerns about a service you provide and how the policy applies, contact your carrier and explore available options. As always, check with your carriers prior to providing a service or device that may be addressed by medical policy.


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