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Coverage Policies and Guidelines

Find more information about our medical policies, utilization management guidelines and administrative services policies. You can also see newly approved policies and guidelines, and offer feedback on developing policies and updates. Just click on the appropriate link below:

Medical Policies

Utilization Management Guidelines

Administrative Services Policies

Medical Policy Criteria

Medical policies are based on evidence-based research aimed at determining the scientific merit of a particular medical technology. We make these determinations using the following criteria:

  • 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. You can find definitions of these terms in the glossary. Many policies also include medical appropriateness criteria. These criteria are used to determine 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.


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