Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Medical Policy
Medical and Behavioral
Health Policy
Development
Medical and behavioral health policies are developed by the Blue
Cross and Blue Shield of Minnesota (Blue Cross) Medical and
Behavioral Health Policy Committee, which is comprised of
practicing physicians and providers representing a variety of
specialties in the local community and one Blue Cross
representative.
Blue Cross makes its determination of experimental, investigative
or unproven based upon a preponderance of evidence after the
examination of the following reliable evidence, none of which
shall be determinative in and of itself:
1. Whether there is final approval from the appropriate
government regulatory agency, if approval is required;
2. Whether there are consensus opinions and recommendations
reported in relevant scientific and medical literature, peerreviewed
journals, or the reports of clinical trial committees
and other assessment bodies; and
3. Whether there are consensus opinions of national and local
health care providers in the applicable specialty or subspecialty
that typically manages the condition as determined by a survey
or poll of a representative sampling of these providers.
The committee considers a number of additional factors when
evaluating each of the criteria. These factors include, but are not
limited to: quality of the available peer-reviewed medical
literature; safety, effectiveness, appropriateness of technology;
Blue Cross and Blue Shield Association requirements and Medical
Policies; and the relevant impact and consequences of coverage for
the technology (for example, patient, Blue Cross, ethical, societal,
legal).
A drug, device, medical treatment, diagnostic procedure,
technology or procedure for which reliable evidence does not
permit conclusions concerning its safety, effectiveness, or effect on
health outcomes. Blue Cross bases its decision upon an
examination of the following reliable evidence, none of which is
determinative in and of itself.
Drugs and devices cannot be lawfully marketed without the
approval of the U.S. Food and Drug Administration and approval
for marketing has not been given at the time the drug or device is
furnished.
4-8 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)