Priority Health Medical Policies

Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations and general coverage and benefit conditions; if there are none, our medical policy will apply.

Medical Policy Development Process

Medical policies are developed, regularly reviewed, updated, and approved by Priority Health’s Medical Affairs Committee. Medical policies are presented on an annual basis, or as needed if outside the annual review cycle, to the Medical Affairs Committee. This committee is comprised of Priority Health leadership, medical directors, behavioral health practitioners, and practicing non-Priority Health employed physicians presenting primary and specialty care.

New medical policies are developed as needed. Medical policies are created and updated through an extensive review and analysis of the currently available clinical literature including but not limited to: peer-reviewed medical journals, specialty organizations, expert opinions, national treatment guidelines, medical research web sites, medical textbooks, and input from providers and clinicians. In each Medical policy, the reference and description sections outline the evidence sources and rationale for the Medical policy.

In addition to the review of clinical literature and current treatment practices, Priority Health convenes a Medical Technology Assessment Committee of non-Priority Health employed clinicians to review and evaluate new medical and behavioral health procedures, therapies, devices, equipment and prevention strategies or new applications of existing technologies.

Priority Health may also adopt criteria developed by third parties (e.g. InterQual, eviCore, etc.) who are held to the same standards for criteria development, review, revision and approval.

For Medicare, Priority Health complies with National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) and in circumstances where the specific indications are not listed or an NCD or LCD does not set forth coverage criteria, Priority Health medical policy and criteria may apply. The criteria are intended to provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services.

Medically/Clinically Necessary

Priority Health’s medical policies express the determination of whether a medical, surgical, or behavioral service or supply is proven to be effective for health outcomes based on the published clinical evidence. They may be used to decide whether a given health service is medically/clinically necessary.

Medically/clinically necessary is defined as services or supplies needed to diagnose or treat a physical or behavioral health condition. To be considered Medically/Clinically Necessary, the services or supplies must:

  • Have final marketing approval or clearance from/by the Food and Drug Administration (FDA) or appropriate governmental regulatory bodies;
  • Be widely accepted as effective on health outcomes;
  • Be appropriate for the condition or diagnosis;
  • Be essential, based upon nationally accepted evidence-based standards;
  • Yield a comparable health outcome as established alternatives or standard of care
  • Be the most appropriate level of care and site of service which can be safely and reasonably provided.
  • In addition, for procedural services the following apply:
    • Surgically appropriate for the condition or diagnosis based on nationally accepted, evidence-based standards; and
    • Personally appropriate based on shared-decision making and fully informed consent; and
    • Medically appropriate based on adequate management of medical comorbidities and risk factors for death or complications

Prior authorization for certain drugs, services, and procedures may be required. In these cases, providers may need to submit clinical documentation and medical records supporting that the drug, service, or procedure is medically necessary.

Medical criteria 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.

Coverage Determination

Medical policies are developed to assist in administering plan benefits and are not offers of coverage or medical advice.

The determination of whether proposed care is a covered service is independent of, and should not be confused with, the determination of whether proposed care is Medically/Clinically Necessary. Determinations of coverage are based on plan documents, a member’s specific benefits, Federal and state laws, and Priority Health medical policy when applicable.

InterQual® criteria

Priority Health has discontinued some medical policies and now uses InterQual criteria.

Upcoming medical policies changes

Review upcoming changes to our medical policies in the Policy changes list.

Current medical policies

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Note: "CPT" (Current Procedure Terminology) is a registered trademark of the American Medical Association, U.S. Patent & Trademark Office Serial #76379850. The CPT Coding Manual itself is also copyrighted, U.S. Copyright Office Serial # CSN0096041. As a result, we have included the following disclaimer on our medical policies: All Current Procedure Terminology CPT) codes, descriptions, and other data are copyrighted by the American Medical Association.