A service is

“medically necessary” or a “medical necessity”

when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.  (2014 ACA Sample EOC Page 166) CA WIC  §14059.5

Medically Necessary shall mean health care services that a Physician, exercising professional clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

In accordance with generally accepted standards of medical practice, Illinois Dept of Insurance Definition

CIGNA’s Definition

The Five Dimensions of the Medical Necessity Definition: Industry Practice

The contractual scope of coverage: whether proposed treatment is explicitly included or excluded in the health plan contract

Whether the proposed treatment is consistent with professional standards of practice

Patient safety and setting of the treatment

Whether the treatment is medical in nature or for the convenience of the health professional or patient and family

Treatment cost     samhsa.gov

most definitions incorporate the principle of providing services which are “reasonable and necessary” or “appropriate” in light of clinical standards of practice

Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Glossary Meeicare.Gov   

Article on Medical Necessity at American Academy of Physicians Website

Medical Policies & Clinical UM Guidelines

How to determine if a procedure is Medically Necessary

Does Company X Y Z pay for this or that surgery? 

Like Lap Band Aetna Bulletin on Obesity Surgery (Gastric Bypass) (Lap Band)

Cochlear Implants – Hearing

Clinical Policy Bulletin Index

Blue Cross

Blue Shield Clinical Policies

Spine Policy & Pain Intervention

Lap Band – Severe Obesity PacifiCare – United HealthCare

How do I find a code.com ICD 9, 10, DRG, CPT, (Current Procedural Terminology) diagnosis code, Medical Billing,  coding

Magellan – Medical Necessity Guidelines 

Mental Health? 190 pages

Utilization Review

Oscar  Clinical Guidelines

 
  •  

    Noninvasive Positive Pressure Ventilation (CG003)

  •  

    Oxygen Therapy (CG005)

  •  

    Hospital Beds and Accessories (CG006)

  •  

    Pressure-Reducing Support Surfaces (CG007)

  •  

    Bariatric Surgery (Adults) (CG008)

  •  

    Bariatric Surgery (Adolescents) (CG009)

  •  

    Medical Nutrition Therapy (CG010)

  •  

    Oral Liquid Nutritional Supplements (CG011)

  •  

    Non-Covered Experimental, Investigational, and Unproven Services (CG012)

  •  

    Acupuncture (CG013)

  •  

    Hyperbaric Oxygen Therapy (CG014)

  •  

    Treatment and Removal of Benign Skin Lesions (CG015)

  •  

    Sex Reassignment Surgery (Gender Affirmation Surgery) (CG017)

  •  

    Balloon Ostial Dilation (CG018)

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    Wearable Cardioverter-Defibrillator Devices (CG019)

  •  

    Home Care – Skilled Nursing Care (RN, LVN/LPN) (CG020)

  •  

    Home Care – Physical Therapy (PT) and Occupational Therapy (OT) (CG021)

  •  

    Home Care – Home Health Aides (HHA) (CG022)

  •  

    Home Care – Speech Language Pathology (SLP) Services (CG023)

  •  

    Colorectal Cancer Screening (CG024)

  •  

    Optical Coherence Tomography (OCT) (CG025)

  •  

    Autonomic Testing (CG026)

  •  

    Breast Imaging (CG027)

  •  

    Diabetes Equipment and Supplies (CG028)

  •  

    Insulin Delivery Systems and Continuous Glucose Monitoring (CG029)

  •  

    Bioengineered Skin and Soft Tissue Substitutes (CG030)

  •  

    BPH Treatment (CG031)

  •  

    Ambulatory Cardiac Event Monitoring (CG032)

  •  

    Botulinum Toxin (CG033)

  •  

    Glaucoma Surgery (CG034)

  •  

    Transcranial Doppler (CG035)

  •  

    Breast Procedures (CG036)

  •  

    Erectile Dysfunction (CG037)

  •  

    Home Births (CG038)

  •  

    Contact Lenses and Eyeglasses (CG039)

  •  

    Potentially Preventable Hospital Readmissions (CG040)

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    Anesthesia and Sedation in Endoscopy (CG041)

  •  

    Skilled Nursing Facility Care (CG042)

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    Prenatal Testing (CG043)

  •  

    Outpatient Physical Therapy & Occupational Therapy (CG044)

  •  

    Intraoperative Neuromonitoring (CG045)

 

The Criteria (Clinical UM – Utilization Management)  for establishing the medical necessity of a service:

appropriate for symptoms, diagnosis, and treatment of a condition, illness, or injury; provided for diagnosis, direct care, or treatment; in accordance with the standards of good medical practice; not primarily for the convenience of the member or member’s provider; the most appropriate supply or level of service that can be safely provided to the member. samhsa.gov/

Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease, and Not primarily for the convenience of the patient, 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 patient’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, Physician specialty society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors. Blue Cross ppo_30_eoc Page 108

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Resources – Links 

Big Fines! —  In August 2012, DMHC issued a cease-and-desist order against Accountable Health for allegedly conducting illegal utilization reviews and making medical necessity decisions for insurers. DMHC accused the group’s vice president and another employee of engaging in utilization reviews on behalf of nine health plans, even though the employees are not licensed physicians.

Learn More  CA Health Line 9.10.2015

Wikipedia

References

  1. See 42 U.S.C. § 1395y(a)(1)(A)
  2. See http://www.cms.hhs.gov/mcd/overview.asp
  3. For more information, see Certificate of medical necessity

External links

Kantor & Kantor Law Firm   

Excerpt from Insurance Policy – EOC Evidence of Coverage

The Benefits of this Plan are provided only for Services which are Medically Necessary as defined in this section.  

 

  1. Services which are Medically Necessary include only those which have been established as safe and effective, are furnished under generally accepted professional standards to treat illness, injury or medical condition, and which are:
  1. Consistent with the Plan’s medical policy;
  2. Consistent with the symptoms or diagnosis;
  3. Not furnished primarily for the convenience of the patient, the attending Physician or other provider; and
  4. Furnished at the most appropriate level which can be provided safely and effectively to the patient.

 

  1. If there are two (2) or more Medically Necessary Services that may be provided for the illness, injury, or medical condition, Blue Shield Life will provide benefits based on the most cost-effective Service.

   

  1. Hospital Inpatient Services which are Medically Necessary include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and which could not have been provided in the Physician’s office, the Outpatient department of a Hospital, or in another lesser facility without adversely affecting the patient’s condition or the quality of medical care rendered. Inpatient services not Medically Necessary include hospitalization:

 

  1. For diagnostic studies that could have been provided on an Outpatient basis;
  2. For medical observation or evaluation;
  3. For personal comfort;
  4. In a pain management center to treat or cure chronic pain; and
  5. For Inpatient Rehabilitation that can be provided on an Outpatient basis. Copied from Blue Shield EOC 

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2 comments on “Medical Necessity – reasonable and necessary

    • Sorry, your question is beyond our pay grade. See the CMS link below for complete details only an experienced MD could decipher.

      https://www.medicare.gov/coverage/diagnostic-tests
      Medicare Part B (Medical Insurance) covers medically necessary clinical diagnostic laboratory tests, when your doctor or practitioner orders them. These tests are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare also covers some preventive services to help prevent, find, or manage a medical problem.

      Diagnostic non-laboratory tests
      Part B covers diagnostic non-laboratory tests when these apply:

      Your doctor or other health care provider orders them.
      They’re ordered as part of treating a medical problem.
      Examples of diagnostic non-laboratory tests include CT scans, MRIs, EKGs, X-rays, and PET scans. These tests are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare also covers some preventive services to help prevent, find, or manage a medical problem.

      Bibliography:

      National Coverage Determination (NCD) for Magnetic Resonance Imaging

      https://health.costhelper.com/mri.html
      A spinal MRI is used to find various spinal problems, including nerve damage or tumors. It typically costs $1,000-$5,000,

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