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A Medical and Pharmacy Coverage Policy is created using evidence-based medical research of peer-reviewed medical literature. Medical and Pharmacy Coverage Policies were originally created for internal associates that needed to make determinations about claims and appropriateness of coverage. Medical and Pharmacy Coverage Policies are guidelines. They represent the medical criteria identified by medical research to be safe and effective. Please refer to the Disclaimer.
Each Medical and Pharmacy Coverage Policy may include the following subsections:
Description
This section includes an explanation of the policy topic.
Coverage Determination
This section generally outlines what is covered under the Plan with respect to the policy topic. It will also guide you to where specific information regarding benefit coverage and limits from a member's individual contract may be obtained.
Background
This section contains information regarding the medical condition that is treated with the device, medication, or procedure discussed in the Medical and Pharmacy Coverage Policy.
Medical Alternatives
This section contains information surrounding possible medical alternatives to the device or procedure that is discussed in the Medical and Pharmacy Coverage Policy.
Provider Claims Codes
This section displays a grid containing the Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), or International Classification of Diseases-9 th Revision-Clinical Modification (ICD-9-CM) codes.
The grid displays three columns that are read left to right. The first column contains the corresponding CPT, HCPCS or ICD-9-CM code. The second column displays the code's definition. The third column displays corresponding comments.
Medical Terms
This section contains definitions of medical terminology found within the Medical and Pharmacy Coverage Policy.
References
Much like a book's bibliography, this section details all the titles, authors and publication dates for the articles or publications that have been researched and used for the Medical and Pharmacy Coverage Policy.
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