Systematic Reviews and Medical Policy Determinations

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. IOM Presentation • A Brief Overview of WellPoint’s Medical Policy Process

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. 2006 Oct. AHRQ. Rockville, MD. No. 290-02-0025. Available at:  http://www.cms.hhs.gov/determinationprocess/downloads/id34TA.pdf.  Accessed on January 10,  2008.

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 CriteriaType: 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 *The Medical Policy & Technology Assessment Committee² (MPTAC), Hematology/Oncology Committee (HEM/ONC), and Behavioral Health Committee include external physician representation