Currentpriority healthPolicy 91430-R5

Technology Assessment

Defines Priority Health's ongoing technology assessment process used to review and evaluate new and existing medical procedures, devices, therapies, behavioral health services, prevention strategies, and applications; describes initiating triggers, review resources, decision criteria, approval mechanisms, documentation, and applicability to product lines.

Policy Summary

Payerpriority health

PolicyTechnology Assessment

Policy CodePolicy 91430-R5

Change TypeInformational

Effective DateJun 1, 2024

Next Review Date

Key ActionDocument technology assessment decisions in the case review process, medical policy administration process, and/or committee minutes.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

Review DatesPolicy Review History

Dec 1998Origin Date

2024-06-01Effective Date

Policy Overview

The Technology Assessment Policy establishes an ongoing process to review and evaluate new and existing medical procedures, devices, equipment, therapies, behavioral health services, prevention strategies, and new applications of existing technologies. It is administered through the Medical Technology Assessment Committee (MTAC), which serves in an advisory capacity to the Medical Affairs Committee (MAC). The Medical Director coordinates and prioritizes technology assessment topics, and outcomes of the process include coverage decisions within the benefit structure or changes to the benefit structure.

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Assessments may be initiated proactively (e.g., ongoing literature surveillance and proactive evaluation of emerging technologies) or reactively (e.g., member or provider requests, emergent or urgent member medical conditions, or pre-enrollment requests). The assessment process uses diverse resources to inform decisions, including scientific and medical literature, state and federal regulatory agencies, other federal agencies, professional organizations, managed care industry standards, in-house experts and standing committees, technology assessment information services, participating providers, and external experts/specialists.

Policy Number91430-R5

SubjectTechnology Assessment Policy

StatusCURRENT

Effective Date2024-06-01

Last Review Date2024-05-25

Next Review Date

Scope SummaryDefines Priority Health's ongoing technology assessment process used to review and evaluate new and existing medical procedures, devices, therapies, behavioral health services, prevention strategies, and applications; describes initiating triggers, review resources, decision criteria, approval mechanisms, documentation, and applicability to product lines.

Coverage Stance & Decision Criteria

This policy is informational in nature. Coverage determinations remain subject to each member's specific benefits and plan documents. When a conflict exists between this policy and a plan document, the plan document governs. For Medicare members, CMS determinations prevail when adopted.

Technology Assessment Evidence Criteria for Coverage Decisions

Decisions of coverage, policy formulation, or benefit design use the following criteria:

ALL of the following

Evidence of clear therapeutic effectiveness when used in the general population; includes indications for use, subpopulations most likely to benefit, and contraindications
Evidence of safety when used in the general population; potential harms and long-term abnormal effects are known or understood
Evidence that the medical community in general accepts the safety and effectiveness of the service outside of investigational settings
Evidence of clinically meaningful outcomes; clinical trials or meta-analyses must demonstrate consistent outcomes that matter clinically and are better than or equal to existing alternatives
Evidence that clinically meaningful outcomes can be attained at a reasonable cost to the health care system
Service has been approved by appropriate regulatory bodies, if necessary
Priority Health's plan document language is consistent with the decision
Legal/risk management issues are considered

Scope and Applicability

The policy applies across product lines and is used to evaluate a wide range of products and services, including new and existing procedures, devices, equipment, therapies, behavioral health services, prevention strategies, and new applications of existing technologies. It is applicable to insured HMO/EPO, POS, PPO plans, ASO/self-funded plans, individual policies, Medicare, and Medicaid/Healthy Michigan Plan as described in plan-specific sections.

Coverage determinations under this policy remain subject to member plan language and, where applicable, to Medicare/CMS or state Medicaid manuals and fee schedules. If there is a conflict between this medical policy and a member's plan document or applicable government determinations, the plan document or relevant government determination governs as specified.

Origin DateDecember 1998

Policy Review HistoryReview Dates: 12/98 through 5/25

Effective Date2024-06-01

Advisory/Approval CommitteesMTAC (advisory to MAC) and MAC (provides input/approval for individual case review and medical policy); approvals and documentation involve Medical Director, MAC, MTAC, Quality Integration Committee and other leadership as required.

Technology Assessment Process & Prioritization

Technology Assessment Initiation Prioritization

Topics are coordinated and prioritized by the Medical Director in the following order of importance:

ALL of the following

PRIORITY ORDER (highest to lowest)
- Emergent medical condition of member
- Urgent medical condition of member
- Request of credentialed practitioner/provider
- Proactive evaluation of emerging technologies
- Pre-enrollment request for potential members

Approval Mechanisms

Approvals for technology assessment outcomes occur via:

ANY of the following

Individual case review — Decision by Medical Director with input from Medical Affairs Committee (MAC) as necessary
Medical policy — Approval by Medical Director and Medical Affairs Committee (MAC) per Medical Policy Program
Benefit design changes — Approval by Medical Director, Executive Management Team, Associate VP Product & Market Development, Quality Integration Committee, and State of Michigan Office of Financial and Insurance Services (as applicable)

MTAC advises the Medical Affairs Committee (MAC) on technology assessment matters. The committee process draws on a diverse set of resources when conducting assessments, including scientific and medical literature; state and federal regulatory agencies (e.g., FDA, state health departments); other federal agencies (e.g., NIH, CDC); professional organizations; managed care industry standards; in-house experts and standing committees; technology assessment information services (e.g., HAYES); participating providers; and external experts and specialists.

Provider Documentation & Operational Requirements

Documentation Required

Document technology assessment decisions

Technology assessment decisions must be documented in the case review process, medical policy administration process, and/or committee minutes (Medical Affairs/Quality Integration/Medical Technology Assessment Committees).

Prior Authorization

Coverage subject to member-specific benefits and plan documents

Coverage determinations are subject to the member's specific benefits; if a conflict exists between this policy and a plan document, the plan document governs. For Medicare, CMS determinations prevail when adopted.

For Medicare members, CMS determinations prevail when adopted.

Definitions

MTACMedical Technology Assessment Committee; serves in an advisory capacity to the Medical Affairs Committee.

MACMedical Affairs Committee; involved in approval of medical policy decisions.

MTAC serves in an advisory capacity to MAC. Technology assessment decisions are documented through the case review process, the medical policy administration process, and committee minutes, with approvals coordinated through the Medical Policy Program and routed to committees such as Medical Affairs and Quality Integration as appropriate.

Revision History

December 1998Origin

Date of Origin: December 1998

12/98 through 5/25Review

Policy Review History: Review Dates: 12/98, 12/00, 12/01, 8/02, 11/03, 11/04, 9/05, 8/06, 6/07, 6/08, 6/09, 6/10, 6/11, 6/12, 6/13, 5/14, 5/15, 5/16, 5/17, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, 5/25

2024-05-25Review

Last Review: 2024-05-25

2024-06-01EffectiveLatest

Effective Date: June 1, 2024

Policy Summary

Payerpriority health

PolicyTechnology Assessment

Policy CodePolicy 91430-R5

Change TypeInformational

Effective DateJun 1, 2024

Next Review Date

Key ActionDocument technology assessment decisions in the case review process, medical policy administration process, and/or committee minutes.

SourceLink

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