Medical policies

Medical policies are based on research that provides evidence of scientific merit for a particular medical technology. They are also based on data from the peer-reviewed scientific literature, from criteria developed by specialty societies, from guidelines adopted by other health care organizations and from government agencies, such as the Centers for Medicare & Medicaid Services and the U.S. Food and Drug Administration. Medical policies are used as guidelines for coverage determinations in health care benefit programs, unless otherwise indicated.

These medical policies apply only to members who have health insurance through HealthSpring.

In the event of conflict between a medical policy and any plan document under which a member is entitled to covered services, the plan document will govern. Plan documents include, but are not limited to, Evidence of Coverage, benefit booklets, summary plan descriptions and other coverage documents.

Medical technology is constantly evolving, and these medical policies are subject to change without notice, except as required by law. Additional medical policies may be developed from time to time, and some may be withdrawn from use. The medical policies generally apply to all benefit plans, although some local variations may exist. Members should call the number on their ID card for specific coverage information.

Restrictions and limitations

Medical policies serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage, and some 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, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits.

The medical policies do not constitute medical advice or medical care. They do not guarantee any results or outcomes. Treating health care providers are solely responsible for diagnosis, treatment and medical advice. Members should discuss the information in the medical policies with their treating health care providers. HealthSpring is not a provider of health care and does not render medical advice.

Medical policies can be highly technical and complex and are provided here for informational purposes.

HealthSpring is under no obligation to update this site. Therefore, the medical policies displayed may be out of date. Contact your provider representative if you have any questions. Medical policies are interpreted and applied at the sole discretion of HealthSpring.

Medical policies are interpreted and applied at the sole discretion of HealthSpring. Refer to our provider manual for more details.