Medical Policy

The Medical Policy Department, in collaboration with physician specialists, develop and maintain medical necessity and coverage guidelines for all medical-surgical products for the Commercial and Medicare Advantage lines of business. These guidelines address medical services, including diagnostic and therapeutic procedures, injectable drugs, and durable medical equipment. We review our existing medical policies to reflect scientific-based evidence and the current standard-of-care. Procedure codes and diagnosis codes applied to each policy are integrated into the claims processing system which ensures accurate administration of member benefits.

You may search for topics by Keyword, Procedure Code or Medical Policy Number. 

Select the Medical Policy type to be viewed:

  • Highmark Medical Policy Search
    Medical policy guidelines for all of Highmark's medical-surgical products, including managed care.
  • Medicare Advantage Medical Policy Search
    Highmark adheres to the Centers for Medicare and Medicaid Services (CMS) coverage determinations for Medicare Advantage (MA) membership. The link above will take you to the CMS site where you can search National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs).

Medical Policy Update Newsletter - Medical Policy Update is a monthly newsletter for the health care providers who participate in our networks and submit claims to Highmark using the appropriate HIPAA transactions or claim forms as required by Highmark.

Preferred Products for Medicare Advantage

Medical Policy Frequently Asked Questions (FAQs)

  • MCG Clinical Criteria - Information on Highmark's incorporation of MCG Health evidence-based clinical guidelines into Highmark’s criteria of clinical decision support.
Last updated on 2/28/2024 1:36:57 PM


Mission Statement

The mission of the Medical Policy Department is to develop and maintain evidence-based coverage guidelines and monitor/assess the medical technology* pipeline to anticipate and plan for the evolution of therapies to ensure appropriate benefit adjudication, patient safety and optimized therapy for our customers. 

Highmark is a nationally recognized industry leader in developing and implementing up-to-date, medically sound policy guidelines. There are many policy guidelines addressing medical technology, therapeutic procedures, medical equipment and supplies, and behavioral health. Medical policy coverage guidelines are developed and maintained in accordance with all applicable laws and regulations, standards of regulatory and accreditation agencies such as NCQA and the national Blue Cross Blue Shield Association (BCBSA). They are used to administer all Highmark medical-surgical products and various fee schedule products.

In addition to commercial products, we also maintain medical policy coverage guidelines for our Medicare Advantage products. The Centers for Medicare and Medicaid Services (CMS) requires that Medicare Advantage insurers use CMS national policy and the regional Medicare Part B Carrier's local policy for Medicare Advantage products.

*Medical technology includes any intervention or service to treat any medical/surgical condition.  These technologies may include drugs, devices, procedures and/or gene therapy.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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