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Complementary and Alternative Medicine/'Wellness' Guideline, 2nd Edition - 2009 Update
Apollo Managed Care Consultants, March 2009, Pages: 237
A toolbox of general information, guidelines and benefit interpretation for the effective clinical and resource management of alternative medicine and preventive health care services. Includes alternative medicine clinical review criteria guidelines, resources, references, web sites ++ preventive health care ('Wellness') guidelines listed by age & sex and the Prevention of coronary artery disease & stroke guideline - all with resources and references.
Preface:
This ‘single topic’ medical review criteria/informational guideline has been developed to provide a representative model for common, acceptable, customary, reasonable and necessary care contract benefit interpretations and objective evidence-based review for authorization (or denial) of services. Each guideline must be reviewed by the medical policy committee of the HMO or contracted/delegated medical group, modified and adapted as appropriate. It is strongly recommended that all applicable documents that will be used to manage medical care in the organization be sent to affected providers for review and comment prior to implementation. This will always promote an understanding of the guideline, avoid compliance issues, and frequently improve the document by additional input. Cost effective health care is quality driven (true quality, that is; not excessive care) and attention must always be focused on the issues that will result in optimal medical/surgical outcomes in a specific local medical environment.
Once adopted, all policies, procedures, guidelines, protocols, benefit interpretations, review criteria, pathways and the like should be reviewed at least every two years and preferably at annual intervals. In some cases, even more frequently, as clinically significant changes occur due to new technology, medications or practices entering the medical mainstream. The sources of the information in a guideline, whenever possible, should be included as a reference or footnote.
Use clear and unambiguous language in a stated policy or procedure. Avoid any implications of guaranteed clinical results or outcomes as a result of following a particular guideline. All policies, procedures, guidelines and similar criteria should be followed consistently, significant variations noted with justification, and be a written form available for dissemination.
When using this single topic publication, it should be noted that the policies/guidelines are all subject to contractual limitations and changes that occur periodically based on objective studies in the medical literature, recommendations by national bodies such as the AMA, ACP, HCFA and/or other objective sources of new information as well as decisions of local medical groups prior to implementation.
The benefit determination should have been accomplished in an initial and prior step as a separate consideration prior to any review for authorization on the basis of medical necessity. To assure an organized process for the compilation, approval and distribution of medical policy, procedures, guidelines and related information - all policies or guidelines proposed for use by any physician or medical organization should be submitted to the Medical Director or Vice President, Medical Services for a detailed review, circulation to others in the organization and specific approval prior to implementation.
A review of clinical information to make a benefit and/or medical necessity determination should not be confused with a ‘second opinion’. The reviewer has no actual or potential role in the care of the patient. The determination resulting from the review process relates only to payment (or non-payment) for services rendered
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