How Policies Are Developed

We strive to offer our members the latest in proven medical technologies by reviewing current scientific evidence and expert physician opinion. We incorporate input from the Massachusetts Medical Society, specialty societies, national technology review organizations, and community physicians in the development and review of all policies.

Advancement in medical technology is monitored internally by Blue Cross. We use information from journals, technology assessment databases, and regulatory agencies to create our policies. Policy changes from the National Blue Cross and Blue Shield Medical Policy Program are monitored monthly. We also review guidance from the Centers for Medicare and Medicaid Services (CMS) and the local Medicare Program are monitored via the CMS website.

Blue Plans use the National Blue Cross and Blue Shield Medical Policy Program 

The Blue Cross and Blue Shield Association has a technology assessment program that Blue Plans nationwide draw from to develop medical policies. Blue Cross Blue Shield of Massachusetts is a sponsoring plan. As a sponsor, we participate in the selection of topics that are assessed. We also have ongoing representation in the Blue Cross Blue Shield Association’s Medical Policy Panel.

Overseeing the work of the Blue Cross Blue Shield Association’s Medical Policy Program is the Medical Advisory Panel, which is comprised of independent, nationally recognized experts in technology assessment, clinical research and medical specialties. The Medical Advisory Panel includes representatives from the American College of Physicians, American College of Medical Genetics, American Academy of Family Physicians, American College of Cardiology, American Academy of Pediatrics, and the American College of Surgeons.

The Blue Cross Blue Shield National Association’s Medical Policy Program produces revised and new National Association medical policies based on medical literature, review of the positions of appropriate national clinical specialty societies and uses the survey-based results of specialty clinical expert opinion from specialists at national academic medical centers. Following the review by the National Medical Policy Panel, a technology will be considered:

• Medically Necessary: The technology met all Medical Policy Program Medical Technology Assessment Guidelines and is:
  • In accordance with generally accepted standards of medical practice
  • Clinically appropriate in terms of type, frequency, extent, site, and duration of care
  • Considered effective for the condition being treated
  • Not primarily for the convenience of the patient, physician, or other health care provider and
  • Not more costly than an alternative that is at least as likely to produce equivalent therapeutic or diagnostic results
  For these purposes, “generally acceptable standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.

• Not Medically Necessary: The technology met all of the Medical Policy Program Medical Technology Assessment Guidelines but did not meet one or more of the additional criteria in above the definition of “medically necessary.”
• Investigational: The technology failed one or more of the Medical Policy Program Medical Technology Assessment Guidelines.

Blue Cross Blue Shield of Massachusetts monitors the Medical Policy Program assessments, and the decisions of the Medical Policy Advisory Panel for any new policies or revisions to existing national policies. If revisions are made to existing policies or if new national policies are developed, Blue Cross Blue Shield of Massachusetts  evaluates the revised or new policies and decides whether to modify or develop policies to reflect these changes.