Medical Guideline Disclaimer

Property of HIP Health Plan of New York. All rights reserved. The treating physician or primary care provider must submit to the Plan the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, the Plan will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how the Plan determines whether certain services or supplies are medically necessary. The Plan established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). The Plan expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by the Plan, as some programs exclude coverage for services or supplies that the Plan considers medically necessary. If there is a discrepancy between this policy and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. CMS's Coverage Issues Manual may be referenced on the following web site: http://www.cms.hhs.gov/manuals/. Website links accurate at time of publication.

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