All of the following services are typically reviewed for medical necessity and utilization

Blue Shield has an established utilization management [UM] program to help ensure that our members receive quality health care. The UM program looks at the healthcare services provided to our members and evaluates whether they are medically necessary, timely, and in keeping with both Blue Shield established guidelines and community standards. This program is structured around the belief that medical decisions should be made by qualified individuals using nationally recognized clinical criteria. 

Our UM decisions are made by qualified medical staff and are based only on appropriateness of care and service, and existence of coverage [i.e., medical necessity within contracted benefits]. Blue Shield does not specifically reward practitioners or other individuals [e.g., medical groups or doctors’ employees] for issuing denials of coverage or service area. There are no financial incentives for UM decision-makers and therefore, Blue Shield does not encourage decisions that result in underutilization.

Medical necessity reviews [for both authorizations and non-authorizations] made by Blue Shield use a hierarchy of criteria. [The specific hierarchy can be found in the Utilization Management Program Description.] These criteria consist of internal medical policies established by the Blue Shield Medical Policy Committee, nationally recognized evidence-based criteria, Milliman Care Guidelines [MCG], National Imaging Associates [NIA] Radiology Clinical Guidelines, Advisory Committee on Immunization Practices [ACIP], and Medication Policies [for non-self-administered drugs such as Injectable and Implantable drugs] established by the Blue Shield Pharmacy & Therapeutics Committee [these criteria and guidelines are adopted with input from network physicians and are regularly reviewed for clinical appropriateness]. Where applicable, criteria established by the Center for Medicare & Medicaid Services [CMS] and DME coverage criteria are utilized. IPA/medical groups must use the most current version of the policies and manage updates to their UM review processes. These policies may be found on blueshieldca.com/provider and may be updated quarterly as needed.

For fully-insured products, Mental Health and Substance Use Disorders reviews are conducted by applying the American Society of Addiction Medicine [ASAM ] criteria, Level of Care Utilization System [LOCUS] guidelines, Child and Adolescent Level of Care Utilization System [CALOCUS] guidelines, Early Childhood Service Intensity Instrument [ECSII] guidelines, and World Professional Association for Transgender Health [WPATH] guidelines. Blue Shield may add additional guidelines from nonprofit professional associations as they become available in accordance with the revised California Mental Health Parity Act.

Coverage for medically necessary treatment of mental health and substance use disorders, is provided under the same terms and conditions applied to other medical conditions. “Medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of an illness, injury, condition, or its symptoms, in a manner that is all of the following:

• In accordance with the generally accepted standards of mental health and substance use disorder care;
• Clinically appropriate in terms of type, frequency, extent, site, and duration; and
• Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.

To request Utilization Management criteria or with questions, contact UM staff by phone or fax:

Phone:[800] 541-6652 [option #6]

Fax: [844] 807-8996

Blue Shield's policy for UM decisions can also be found in the HMO IPA/Medical Group Procedures Manual.

The information about utilization management for Blue Shield of California Promise Health Plan providers can be found on Utilization management and clinical practice guidelines page.

Cigna defines Medical Necessity in the following four ways:

• Medical Necessity for Physicians
• Medical Necessity for other Health Care Providers
• Health Care for Seniors Definition of Medical Necessity for Physicians
• Health Care for Seniors Definition of Medical Necessity for other Health Care Providers

Full descriptions of each are given below.

Cigna's Definition of Medical Necessity for Physicians

"Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
2. Physician Specialty Society recommendations
3. The views of physicians practicing in the relevant clinical area
4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Cigna's Seniors Definition of Medical Necessity for other Health Care Providers

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community
2. Physician and Health Care Provider Specialty Society recommendations
3. The views of physicians and health care providers practicing in relevant clinical areas
4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Cigna's Seniors Definition of Medical Necessity for Physicians

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
2. Physician Specialty Society recommendations
3. The views of physicians practicing in the relevant clinical area
4. Any other relevant factors

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Cigna's Seniors Definition of Medical Necessity for other Health Care Providers

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" shall mean health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community
2. Physician and Health Care Provider Specialty Society recommendations
3. The views of physicians and health care providers practicing in relevant clinical areas
4. Any other relevant factors

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Medical Necessity Criteria for Treatment of Mental Health and Substance Use Disorders

Cigna believes that all treatment decisions that are made in alignment with the Medical Necessity Criteria must be first and foremost clinically based. Care must be patient-centered and take into account the individuals’ needs, clinical and environmental factors, and personal values.

Learn more about our Behavioral Health Guidelines.

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