Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Medical Necessity
Policy #:MA12.008

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

As defined by Title XVIII of the Social Security Act, Section 1862(a)(1)(A),(1), and as noted in Evidence of Coverage, services, supplies, or drugs needed for the prevention, diagnosis, or treatment of a medical condition and meet accepted standards of medical practice are considered medically necessary and, therefore, covered when the applicable medical necessity criteria are met.

The Company does not cover services that do not meet the definition of medical necessity, such as experimental/investigational, cosmetic, or not medically necessary services because these services are not covered by Medicare.

FAILURE TO USE DESIGNATED PROVIDER

HEALTH MAINTENANCE ORGANIZATION (HMO)
HMO and HMO Point-of-Service (HMO-POS) products may require that the member obtain medically necessary services (e.g., Laboratory, Radiology) at the Primary Care Provider’s (PCP’s) Designated Provider. In most cases, services that that are rendered at a non-Designated Provider for members enrolled in HMO or HMO-POS products are not eligible for reimbursement consideration by the Company, with certain exceptions (e.g., medically necessary service cannot be provided at the Designated Provider).

PLACE OF SERVICE

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination.

Designation of a code and/or fee does not imply reimbursement.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, medically necessary services are covered by the Company when the applicable medical necessity criteria are met.

Description

Medical Necessity is the term used in Evidence of Coverage to evaluate coverage for health care services, procedures, devices, and pharmaceuticals.
References

Evidence of Coverage.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA12.008:
02/13/2019This policy has been reissued in accordance with the Company's annual review process.
04/25/2018The policy has been reviewed and reissued to communicate the criteria the Company utilizes to determine medical necessity.
07/01/2017New policy number MA12.008 has been developed to communicate criteria the Company utilizes to determine medical necessity.





Version Effective Date: 07/01/2017
Version Issued Date: 06/30/2017
Version Reissued Date: 02/14/2019