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REMINDER: Coverage of Investigational and Cosmetic Services

Blue Cross and Blue Shield of North Carolina (BCBSNC) member's benefits do not typically cover investigational or cosmetic services and will not allow reimbursement for any services, procedures or supplies associated with these services. Beginning September 1, 2009, all claims submitted by professional providers and facilities (institutional providers) for services deemed investigational or cosmetic, as well as, all services, procedures or supplies associated with those services will be denied.

What is considered investigational and/or cosmetic? Outlined below is the criteria that will determine if the service(s) will be deemed Investigational and/or Cosmetic.

Investigational (Experimental)- The use of a service or supply, including but not limited to treatment, procedure, facility, equipment, drug or device that BCBSNC does not recognize as standard medical care of the condition, disease, illness or injury being treated. The following criteria are the basis for BCBSNC's determination that a service of supply is investigational:

  • Services or supplies requiring federal or other governmental body approval, such as drugs and devices that do not have unrestricted market approval from the Food and Drug Administration "FDA" for final approval from any other governmental regulatory body for use in treatment of a specified condition. Any approval that is granted as an interim step in the regulatory process is nota substitute for final or unrestricted market approval.
  • There is insufficient or inconclusive scientific evidence in peer-reviewed medical literature to permit BCBSNC's evaluation of the therapeutic value of the service or supply.
  • There is inconclusive evidence that the service or supply has a beneficial effect on health outcomes.
  • The service or supply under consideration is not as beneficial as other established alternatives.
  • There is insufficient information or inconclusive scientific evidence that, when utilized in a non-investigational setting, the service or supply has a beneficial effect on health outcomes and is as beneficial as any established alternatives.
  • If a service or supply meets one or more of the criteria, it is deemed investigational. Determinations are made solely by BCBSNC after independent review of scientific data. Opinions of experts in a particular field and/or opinions and assessments of nationally recognized review organizations may also be considered by BCBSNC but are not determinative, nor conclusive. Refer to Medical Policy Investigational (Experimental) Services at http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/investigational_(experimental)_services.pdf

Cosmetic - those services intended to improve appearance and not primarily to restore bodily function or to correct significant deformity resulting from accidental injury, trauma, or previous therapeutic process. Refer to Medical Policy Cosmetic and Reconstructive Surgery at http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/cosmetic_and_reconstructive_surgery.pdf