Medical Policy

THESE CRITERIA ARE USED IN THE DEVELOPMENT AND UPDATING OF MEDICAL POLICIES AND CLINICAL UM GUIDELINES. AS THESE CRITERIA MAY NOT BE THE CRITERIA USED IN THE DEFINITION OF MEDICAL NECESSITY WITHIN THE COVERED INDIVIDUAL’S PLAN DOCUMENT, THE DEFINITION IN THE COVERED INDIVIDUAL’S PLAN DOCUMENT IS TO BE USED FOR BENEFIT DETERMINATIONS (SEE COVERED INDIVIDUAL’S BENEFIT PLAN FOR SPECIFIC CONTRACT LANGUAGE).

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

"Medically Necessary" services are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

• in accordance with generally accepted standards of medical practice; and
• clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the covered individual’s illness, injury or disease; and
• not primarily for the convenience of the covered individual, physician or other health care provider; and
• not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered individual's illness, injury or disease.

For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.

This document explains how “medically necessary” health services are defined.

Medically necessary services can include procedures, treatments, supplies, devices, equipment, facilities, or drugs. A service is considered medically necessary when a healthcare professional uses careful clinical judgment and decides it is needed to prevent, check, diagnose, or treat an illness, injury, disease, or related symptoms. The service must follow accepted medical standards, be appropriate for the person’s condition, not be mainly to make things easier for the person or others, and not cost more than another option that works just as well.

What the Studies Need to Show

To decide if a service is medically necessary, healthcare professionals rely on generally accepted standards of medical practice. These standards are based on trustworthy scientific evidence published in peer reviewed medical journals. This means experts in the field have reviewed the research before publication. They may also include recommendations from national medical specialty societies and the views of doctors who practice in the relevant area of care.

A service must be appropriate in type, frequency, extent, site, and duration for the person’s specific health problem. It must also be shown to be effective for that condition. The service cannot be mainly to make things easier for the person, the doctor, or another healthcare provider. In addition, it should not cost more than another service that is expected to give similar results in diagnosing or treating the condition.

Medical Necessary services are clinically appropriate

A service is clinically appropriate when it meets all of the following conditions:

• It follows generally accepted medical standards based on credible scientific evidence; and
• It is appropriate in type, frequency, extent, site, and duration for the person’s illness, injury, or disease and is considered effective; and
• It is not mainly to make things easier; and
• It is not more costly than another service that is expected to produce similar results.

Services that do not meet all of these conditions are not clinically appropriate because they do not fit accepted medical standards for the condition being treated.

(Return)

Medical Necessity
Medical Necessity Criteria
Medically Necessary

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

© CPT Only – American Medical Association