Policies

Network Health Medical Policy Development and Application

Network Health’s medical policies list the criteria our clinicians use to decide when medical services are considered “reasonable and necessary” (also called “medically necessary”).

Centers for Medicare & Medicaid Services (CMS) require MA plans to provide the same medical benefits as original Medicare. MA plans must follow National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). They must also follow general coverage and benefit conditions in original Medicare laws. That includes using the same coverage criteria to decide if an item or service is covered by original Medicare.

There are times when a Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria. When that happens, CMS allows MA plans like Network Health to create and use our own internal coverage policies. We must base those policies on current evidence in widely used treatment guidelines or clinical literature. And they must be publicly accessible (listed above).
(42 CFR 422.101(6) (i)):
(i) Coverage criteria not fully established. Coverage criteria are not fully established when:

1. Additional, unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently. The MA organization must demonstrate that the additional criteria provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services;
2. NCDs or LCDs include flexibility that explicitly allows for coverage in circumstances beyond the specific indications that are listed in an NCD or LCD; or
3. There is an absence of any applicable Medicare statutes, regulations, NCDs or LCDs setting forth coverage criteria.

We will only use an internal coverage policy for a customer’s specific condition when a Medicare policy, an NCD or LCD is not fully established. CMS policies are not fully established when any of the following apply :

• More criteria are needed to interpret or support general provisions in an NCD, LCD or other Medicare coverage policy; or
• There is flexibility allowed in an NCD or LCD; or
• There is no applicable NCD or LCD to decide medical necessity; or
• There is no applicable Local Coverage Article (used with an LCD) to decide medical necessity; or
• A Medicare policy does not address the customer’s specific condition for the request under review; or
• A Medicare policy does not include specific coverage criteria. A Medicare policy may have broad guidelines, but it may not have enough detail to decide if the request is medically necessary.

Additionally, we may use our own policies when a Medicare policy allows for more coverage than what is written in the Medicare policy. When our clinicians use internal clinical criteria, each customer’s unique clinical situation is considered with current CMS guidelines and our clinical policies, as applicable.