COVERAGE POLICIES AND CRITERIA

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Viva Health COVERAGE POLICIES AND CRITERIA

GENERAL STATEMENT

The Viva Health Coverage Policies and Criteria contain Policies approved by Viva. Policies are based upon criteria from the Centers of Medicare & Medicaid Services (CMS), CMS approved drug compendia, or scientific evidence of merit for a particular medication. They represent the medical criteria identified by CMS and by research to be safe and effective. Please refer to the policy disclaimer. The applicable Viva policy is the policy that is in effect at the time of service.

Restrictions and Limitations

  • Policies DO NOT determine the schedule of benefits. Rather, Policies are used in the process of determining whether a service may be medically necessary and appropriate or investigational.
  • Payment will not be made for any use of these drugs outside of the criteria without prior authorization. The member may not be billed unless the member explicitly agrees in writing to be responsible for the charges in accordance with the contract/provider manual. Prior authorization will only be given if the provider demonstrates the intended use meets Medicare coverage guidelines.
  • Policies are interpreted and applied in the sole discretion of the Plan.
  • Policy application is subject to state and federal laws and specific instructions from Plan Sponsors of self-insured groups.
  • Policies DO NOT constitute medical advice and DO NOT guarantee any results or outcomes.
  • Current Procedural Terminology (CPT®) codes and descriptions are the property of the American Medical Association with all rights reserved.

» MEDICARE POLICIES (click to view)

» COMMERCIAL POLICIES (click to view)

LOCAL COVERAGE DETERMINATIONS

MEDICARE POLICIES
COMMERCIAL POLICIES