Plan policy may be central to the determination
Health plans often maintain detailed coverage policies for procedures, diagnostic tests, specialty therapies, DME, genetic testing, emerging technologies and other services.
Advanced cardiac imaging
A cardiologist requests advanced imaging for progressive exertional symptoms. The physician reviewer evaluates symptoms, known coronary disease, prior testing, ability to exercise and the applicable health-plan policy to determine whether the documented circumstances satisfy coverage requirements.
Hereditary cancer testing
The reviewer may evaluate cancer type, age at diagnosis, family history, prior genetic testing, expected impact on management and the plan's current coverage requirements.
Documentation matters
A service can be clinically reasonable yet lack documentation required by an applicable coverage policy. Depending on client workflow, the next step may include additional-information requests, physician review, peer-to-peer discussion or an adverse determination.