The publisher (Apollo Managed Care, Inc.) and authors/editors make no representations or warranties with respect to the accuracy or completeness of the contents of this web site or Apollo publications and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. There are no warranties which extend beyond the descriptions contained in this paragraph. The accuracy and completeness of the information provided herein and opinions stated herein are not guaranteed or warranted to produce any particular results, and the advice and strategies contained herein may not be suitable for every individual or organization. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Apollo Managed Care, Inc. (Apollo) makes diligent efforts to obtain accurate and timely information. However, Apollo disclaims any liability to any party for any loss or damage caused by errors or omissions, whether or not such errors or omissions result from negligence, accident or any other cause.
This information is provided as a general reference and is not intended to address every aspect of a clinical situation that may exist now, or in the future. Physicians and health care professionals must exercise clinical discretion in interpreting and applying guideline information to individual patients. Treating providers are solely responsible for the medical advice and treatment of their patients. The use of an Apollo guideline is not a guarantee of payment or a final prediction of how specific claim(s) will be adjudicated by the payer(s). Claims payment is subject to eligibility and benefits on the date of service, coordination of benefits, referral/authorization, member's health plan/other payer utilization management guidelines when applicable, and adherence to the member's health plan policies, plan procedures, and claims editing.
Apollo Managed Care, Inc. does not provide insurance nor medical services nor advice (business or healthcare-related). The purpose of any utilization management policy is to provide a guide to potential benefit coverage. Utilization management policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care. Treating providers are solely responsible for the medical evaluation and treatment provided to their patients.
Apollo manuals provide examples (many abstracted from authoritative resources such as Medicare or health plan policies) of common, customary, reasonable and medically necessary benefit interpretations and objective evidence-based review guidelines for authorization (or denial) of services.
A 'benefit interpretation' is a document that describes an issue as it relates to insurance coverage (read source of payment). Coverage may vary from one company to another, and from contract to contract within a given company. Coverage provides payment for services. It has no other function related to the care of a patient. Policies are designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Apollo's recommendation as to whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic are based on a review of currently available clinical information (e.g., clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other authoritative resources). Apollo makes no representations and accepts no liability with respect to the content of any external information cited or relied upon. The discussion, analysis, conclusions and positions, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Apollo's opinion and are made without any intent to defame. Apollo expressly reserves the right to revise these conclusions without prior notice as new clinical information emerges, and welcomes relevant information including a notice of a perceived need for correction of any factual error.
Benefit determinations should be based in all cases on the member's applicable contract language. To the extent there are any conflicts between Apollo guidelines and contract language, the member's contract language will control/prevail. Each benefit plan defines those services or equipment and supplies that are covered, excluded, and/or subject to dollar caps or other limits. Consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to a given service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by any health plan) for a specific patient.