medical policy manual

medical policy manual

The Medical Policy Manual contains Medical Policies approved by BlueCross BlueShield of Tennessee (BCBST). BCBST Medical Policies largely address new medical technologies and new applications of old medical technologies. General Policies contain lists of diagnostic and therapeutic Medical Policies related to specific disease states. Example: we have a General Policy for Diabetes and a Medical Policy titled Laser Device for Obtaining Blood Sample. Before using the manual, please see our disclaimer.

Other Policies

Medical Policy Criteria

Medical policies are based on an evidence-based research process that seeks to determine the scientific merit of a particular medical technology. Determinations with respect to technologies are made using technology evaluation criteria. The criteria are as follows:

  • The technology must have final approval from the appropriate governmental regulatory bodies.
  • The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.
  • The technology must improve the net health outcome.
  • The technology must be as beneficial as any established alternatives.
  • The improvement must be attainable outside the investigational settings

Medical Policies state whether a technology is medically necessary, not medically necessary, investigational, or cosmetic. Definitions of these terms are found within the glossary. Many policies also contain medical appropriateness criteria. These criteria are used in determining whether a particular technology is appropriate in a particular situation (e.g., for a specific individual).

Internet Disclaimer

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals.

In regards to Medicare claims, CMS may have policies that preclude the medical policies contained in the BCBST Medical Policy Manual.