Review Methodology

The methodology employed for each case depends on the complexity of the review.

Criteria Based

  • Usually provided by a single credentialed physician/clinician reviewer
  • Reviewers consider national and health plan-specific clinical criteria or guidelines
  • Criteria are based on medical consensus, normative patterns of care and/or applicable scientific research
  • Clinical criteria- and guideline-based reviews are most applicable for healthcare services/procedures/treatments that are not new, controversial and/or changing rapidly
  • Questions or disputes typically involve the cosmetic, custodial, convenience, educational or maintenance nature of the service vs. its medical necessity

Evidence Based

  • Expert opinion of the reviewer is informed by an evidence-based approach to questions related to medical necessity or the experimental/investigational status of the proposed treatment/procedure
  • Reviews may involve complex diagnoses; disabling, progressive conditions; and terminal illnesses
  • Reviewers consider scientific evidence supporting safety, effectiveness and medical necessity of proposed controversial medical treatments and procedures
  • Conducted by single reviewer or panel of three reviewers, if consensus decisions are required
  • Written conclusions and rationale are supported with references from the peer-reviewed medical research literature

Opinion Only

  • Expert Opinion on medical necessity and/or medical appropriateness of a proposed or denied treatment, procedure or healthcare service
  • Generally provided by a single medical practitioner
  • Reviews are not evidence or criteria based

Benefit Coverage

  • Coverage for a medical service, procedure or treatment has been denied for contractual vs. medical reasons
  • Involves appeals where Certificate of Coverage is interpreted by the plan as excluding the proposed or disputed service
  • Single reviewer is usually required for this type of review
  • Reviewers are trained and experienced in health benefit contract interpretation
  • Attorney oversight of these reviews