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Medical Policies

Medical and Pharmacy Policies

Please read before continuing.
Medical policies are developed to assist in making coverage determinations under our health policies or plans. These policies are for informational purposes only and do not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services listed in these policies.

Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific limitations and exclusions, and applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical policies in their coverage determinations. For specific plan, benefit, and network status information, please contact Customer Service at the number listed on the member ID card.

Medical policies are based on constantly changing medical science, are reviewed annually, and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health to assist in administering health benefits. These medical policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider.

For specific patient-related policy or medical coding inquiries, please contact the Medical Management Department with the patient’s name and ID card number, along with the procedure, service, or treatment in question. 

Phone: 920-490-6901  
Toll-Free: 888-711-1444
Fax: 920-490-6943
Mail: Aspirus Arise
Attn: Medical Management Department
P.O. Box 11625
Green Bay, WI 54307-1625


We welcome your feedback regarding medical policies or MCG Health guidelines.
For questions or comments regarding research and evidence development of a specific criteria, general medical policy, or MCG Health questions, contact the Medical Policy Committee at medical.policies@wpsic.com.

To request an assessment of new technology or medical policy criteria by the Medical Policy Committee, please complete the New Technology and Medical Policy Assessment Request Form, attach supporting documentation from peer-reviewed high-level scientific literature, and email to the committee at medical.policies@wpsic.com

For questions regarding medical coding related to policies, contact the Code Governance Committee at codegovernance@wpsic.com.

NOTE: The email addresses above should NOT be used to send personal health records or member identified information. This disclaimer applies to all past and present medical and pharmacy policies.

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