I visited the Blue Cross / Blue Shield of Tennessee web site and found this information:

We determine medical necessity when we do careful and thorough research that shows whether the service is:

consistent with the symptoms or diagnosis of the subscriber’s condition, disease, ailment or injury;

meeting standards of good medical practice;

not mainly for convenience instead of need;

and the most appropriate supply or level of service that can safely be given to the subscriber.

When applied to the care of an inpatient, it also means that the subscriber’s medical condition requires a hospital stay to be sure the care is given safely.

The fact that a physician has prescribed, performed, ordered, recommended or approved a service does not in itself make it medically necessary and appropriate.

Importantly, we take into account not just whether a service or drug can be considered medically necessary. We also do the necessary research to find out if the service or drug has been found to be medically necessary for a particular condition or conditions, but not for others.

Policies based on science, medical professionals’ standards.
With our status as Tennessee’s leader in health care financing, our customers count on us to make unbiased claims payment decisions based on the most up-to-date standards of medical care. Those standards are determined by nationally recognized sources such as the National Institute of Health, the Centers for Disease Control and Prevention, and the American Medical Association. In making policy decisions about technology, BCBST uses as a resource Internet searches and numerous organizations that evaluate medical technology, including highly respected sources such as Hayes and ECRI.

We also consider it very important to listen to input from physicians and other health care providers in Tennessee in making policy decisions.

Experimental/Investigative aspects of care must be considered. When a certain type of treatment or drug is being considered for a particular condition, but the data on the effectiveness of the treatment/drug on that condition is insufficient to determine its value, it may be classified as Experimental or Investigative (E/I). BCBST is careful to use a fair and thorough approach in deciding which medical supplies and procedures should be classified in the E/I category, as we can only responsibly provide benefits for treatments that are not investigative.

We have numerous sources we turn to in order to make the determination. The sources are:

--The Hayes, ECRI and similar research organizations and outlets mentioned above,
--The American Medical Association’s Diagnostic And Therapeutic Technology Assessment (DATTA), a consensus from a panel of physicians,
--The BlueCross and BlueShield Association’s Technology Evaluation center,
--Peer-reviewed medical literature, and
--Contacts with network and contracted Tennessee providers.

At BlueCross BlueShield of Tennessee, we lean heavily on the medical community’s consensus in making determinations about "investigative" services or drugs. It is one of the ways in which we ensure that BCBST remains sensitive to providers’ views on what’s best for their patients.

Technology benefit decisions result of rigorous review.
The rapid advance of modern technology and medical breakthroughs make for a complex atmosphere for BlueCross BlueShield of Tennessee when it must make policy on which new medical technologies to approve for benefits. BCBST is committed to keeping its benefits up to date with current medical practices.

Medical technology benefit issues are identified in a number of ways, including benefit interpretations, provider concerns, marketing considerations, financial and legal issues, and operations problems. Also of key importance is whether a current technology is outdated or may be used in a new way, and the importance of evolving or emerging technology.

When the need for a possible review of policy is identified, a staff of licensed nurses conducts preliminary research. A thorough review is also conducted by BCBST’s Medical Technology Assessment Committee, looking at the issue in the context of information from reputable technology assessment organizations, from Medline searches and other Internet sources, and from medical literature, journals, centers of excellence and other network providers. From that point, the Technology Assessment committee (made up of medical directors, network physicians and support staff) will evaluate the executive summary and background research when needed, apply BlueCross BlueShield Association criteria, and search for a medical consensus.

Criteria for technology assessment approval include:
· government approval
· conclusive scientific evidence re: health outcomes
· the technology must improve outcomes
· the benefits must be equal to or greater than that of existing technology
· the results must be attainable outside of the investigational setting

Great majority of claims paid with full benefits
Think that health insurers routinely deny claims?
Not so -- at least with BlueCross BlueShield of Tennessee. Some 93 percent of claims providers send to us are approved for full BCBST payment (within the customer’s contract guidelines) on the claim.
Of the remaining 7 percent, the huge majority qualify for some payment toward some of the charges, and only a very small percentage are denied any benefit payout.

Our claims payment decision-making processes and policies are designed to make sure our customers get the care they need and are not charged for unnecessary or unproven care.

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The above was slightly long but very informative and I hope you picked up on the part about research being made by nurses! I wonder how many practicing physicians are involved in the decision making process?