1. Systematic Reviews and Medical Policy Determinations
Institute of Medicine
January 14, 2010
Alan Rosenberg, M.D. Vice President, Medical Policy, Technology Assessment & Credentialing Programs

2. A Brief Overview of WellPoint’s Medical Policy Process
IOM Presentation
A Brief Overview of WellPoint’s Medical Policy Process
9/17/2018

3. WellPoint Medical Policy Review Process
Annual Policy Review
Changing Practice Patterns
FDA Decisions
New TEC Findings
- External Engagement
- Decision Making
Specialty Societies
Academic Medical Centers
Practicing Experts
Internal Review
Trigger New or Revised Policy
Health Plan Research & Evaluation of Evidence
Policy Formation
Request by Network Providers
Request by Specialty Societies
Request by Practicing Experts
Request by Vendors
Review by HEM/ONC
Sub- Committee*
Review by MPTAC*
Review by Behavioral Health
Sub- Committee*
Monitor Policy Outcomes
Posting Policy Positions on the Internet
MPTAC Adoption of Policy Position
*The Hematology/Oncology Committee¹ (HEM/ONC), Medical Policy & Technology Assessment Committee² (MPTAC) and Behavioral Health Committee³ include external physician representation

4. WellPoint Medical Policy and Technology Assessment Committee (MPTAC)
Multi-disciplinary group including:
External physicians representing diverse medical specialties, clinical practice environments and geographic locations 
Internal WellPoint medical directors
Serves as primary medical policy decision-making body
Two subcommittees: Hematology/Oncology and Behavioral Health
Meets quarterly
Preventive health guidelines and immunization policies recommended by ACIP/CDC are adopted by WellPoint as medically necessary services

5. WellPoint Medical Policy and Technology Assessment Committee (MPTAC)
When making decisions regarding the medical necessity of a technology and/or procedure, MPTAC considers:
"Medically Necessary" are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
in accordance with generally accepted standards of medical practice; and
clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient's illness, injury or disease; and
not primarily for the convenience of the patient, physician or other health care provider; and
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 standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. 

6. Imaging: Cardiac CT Angiography
Coronary Artery Imaging: Contrast-Enhanced Computed Tomography Angiography (CTA) and Cardiac Magnetic Resonance Angiography (MRA)
Government Agency, Medical Society, and Other Authoritative Publications:
3. Agency for Healthcare Research and Quality (AHRQ). Non-Invasive Imaging for Coronary Artery Disease.  Health
Technology Assessment Report conducted at the Duke Evidence-Based Practice Center Oct. AHRQ. Rockville,
MD. No Available at:  Accessed
on January 10,  2008.
9/17/2018

7. Imaging: Cardiac CT Angiography
Cardiac CT Imaging:
Agency for Healthcare Research and Quality
Non-Invasive Imaging for Coronary Artery Disease
Duke Evidence-based Practice Center
October 3, 2006 OR
  ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR
Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging: Appropriateness Criteria Type: Appropriateness Criteria Reference: J Am Coll Cardiol 2006

8. WellPoint Medical Policy: Selection, Formation and Implementation
Enterprise Coding & Implementation Team
Enterprise coding & implementation team works in parallel with policy formation process to formulate system edits, recommend effective dates and maintain communication with operational units
Implementation:
Cascade OMPTA coding grids
Cascade OMPTA policy position change grids
Provide draft copies of updated documents
Post-MPTAC Meetings to communicate policy position and coding changes to (claim and clinical) operational areas
Business units update internal documents and processes and educate review (claim and clinical) staff
IT implementation of coding changes on enterprise claim systems
Provider notification and local decisions regarding implementation date (locally regulated)
Update internal and external websites
Policy Topic Selection Inputs:
WellPoint Staff
FDA Approval
New Codes
New Technology Monitoring
SIU/CIU
Claim Volume and Dollars
CEFMP
Committee for Evaluation for Formation of Medical Policy
“Go No-Go”
Policy Effective Date:
Updated documents available to end-users on Intranet & Internet
Claim systems updated with consistent processing across all platforms
MPTAC*
Medical Policy & Technology Assessment Committee
HEM/ONC Sub-Committee
Behavioral Health Sub-Committee
9/17/2018
*The Medical Policy & Technology Assessment Committee² (MPTAC), Hematology/Oncology Committee (HEM/ONC), and Behavioral Health Committee include external physician representation