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Medical Policy

BCBSWY has developed medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some BCBSWY plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, in effect at the time services are rendered and also subject to applicable state and/or federal laws. Medical policy does not constitute plan authorization, certify coverage availability, or constitute a contract. Medical policies are not an explanation of benefits. These medical policies generally apply to all BCBSWY fully insured benefit plans, although some variations may exist. Additionally, some benefit plans administered by BCBSWY, such as some self-funded employer plans, may not utilize BCBSWY medical policy. Members should contact a BCBSWY Member Services representative for specific coverage information.

Medical policies can be highly technical and complex and are provided here for informational purposes. These medical policies do not constitute medical advice or medical care. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. BCBSWY members should discuss the information in the medical policies with their treating health care providers. Medical policies detail when certain medical services are medically necessary, and whether or not they are investigational. These policies are written to cover a given condition applicable to a majority of people without taking into consideration each individual’s unique, clinical circumstances. Medical policies are medical determinations about a particular technology, service or drug that, while such technology, service or drug may be medically necessary, it is excluded under the terms of a member’s benefit plan. Medical policy is NOT intended to replace independent medical judgment for treatment of individuals.

Medical technology is constantly evolving and these medical policies are subject to change without notice. Additional medical policies may be developed from time to time and some may be withdrawn from use. BCBSWY reserves the right to review and update its medical policies periodically, without notice, and changes may not appear on this web site. BCBSWY makes all coverage determinations based on current medical policy or policies in effect at the time.

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