Important: Medical policies: 
  • are not the same as medical advice and do not guarantee any results or outcomes or coverage. If you are a member, please talk about any health care questions with your health care provider.
  • do not determine benefits. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied.
  • are interpreted and applied at the sole discretion of the Plan, and are subject to state and federal laws.
  • explain when certain medical services are medically necessary and whether or not they are investigational. For more information about medical necessity and investigational (research) criteria, please see these specific policies. Our coverage guidelines are written to cover a given condition for the majority of people. Each individual’s unique, clinical circumstances may be considered.
  • are based on constantly changing medical science. We reserve the right to review and update our policies periodically.

All documents revised November 1, 2021

PA Criteria