What does “medically necessary” and “medical necessity” mean?
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
The Five Dimensions of the Medical Necessity Definition
- 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
The Criteria (Clinical UM – Utilization Management)
for establishing the medical necessity of a service:
The service is 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
Appear to be in Plain English!
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- Home Care – Skilled Nursing Care (RN, LVN/LPN) (CG020) English PDF
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- Home Care – Home Health Aides (HHA) (CG022) English PDF
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- Breast Procedures (CG036) English PDF
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Medical Policies & Clinical UM Guidelines
- 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
How do I find a code.com ICD 9, 10, DRG, CPT, (Current Procedural Terminology) diagnosis code, Medical Billing, coding
- Magellan – Mental Health — Medical Necessity Guidelines for providers
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.
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:
Consistent with the Plan’s medical policy;
Consistent with the symptoms or diagnosis;
Not furnished primarily for the convenience of the patient, the attending Physician or other provider; and
Furnished at the most appropriate level which can be provided safely and effectively to the patient.
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.
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:
For diagnostic studies that could have been provided on an Outpatient basis;
For medical observation or evaluation;
For personal comfort;
In a pain management center to treat or cure chronic pain; and
For Inpatient Rehabilitation that can be provided on an Outpatient basis. Copied from Blue Shield EOC
Video's trying to explain Medical Necessity
- many mental health professionals wonder, "What is medical necessity?"
- Medicare denials for medical necessity on chiropractic claims.
- three components that must be present to establish Medical Necessity for Chiropractic Manipulative treatment (CMT)
- Our webpage on
The U.S. healthcare system wastes close to three-quarters of a trillion dollars a year—and the implications are not just financial. Many of the tests, treatments, and procedures that comprise healthcare waste can expose patients to undue physical, emotional, or financial harm. http://www.milliman.com/waste
An Independent Medical Review (IMR) is where expert independent medical professionals review specific medical decisions made by the insurance company. The California Department of Insurance (CDI) administers an Independent Medical Review program that enables you, the insured, to request an impartial appraisal of medical decisions within certain guidelines as specified by the law.
An IMR can be requested only if the insurance company’s decision involves:
- The medical necessity of a treatment,
- An experimental or investigational therapy for certain medical conditions, or
- A claims denial for emergency or urgent medical services.
It is important to note that the IMR process cannot be used for an insurance company decision that is based on a coverage issue. Only decisions regarding a disputed health care service, as it relates to the practice of medicine, that do not involve a coverage issue are qualified for the IMR program.
You are required to exhaust the internal appeals/grievance process of your particular insurance company before applying for an IMR with the CDI. Click here to read full article on Department of Insurance Website
ONLINE complaint form insurance.ca.gov/complain
Fillable Claim Form
Sections 10169 through 10169.5 of the California Insurance Code (CIC), which became effective January 1, 2001, explain the IMR process in detail. In addition, Section 10145.3 explains the IMR process as it relates to experimental or investigational therapies.
More Links & Resources
Magellan* provides procedures for the expeditious processing of requests for external appeal of adverse determinations through an Independent Review Organization as required by applicable law or customer contract.
To establish standards to assure independent and timely review of disputed health care services to assure that appropriate, beneficial treatment interventions are made available to members. Magellan Mental Health
CA Department of Insurance
Independent Medical Review (IMR) Program
- What Is an Independent Medical Review?
- Who Can Request an Independent Medical Review?
- When Can an Independent Medical Review Be Requested?
- What Issues Are Eligible for an Independent Medical Review?
- What Issues Are Not Eligible for an Independent Medical Review?
- How Does the Independent Medical Review Program Work?
- What Are the Criteria Used in an Independent Medical Review Determination?
- Is There a Way to Process an Independent Medical Review More Quickly in Extraordinary Circumstances?
- Will an Independent Medical Review be Costly?
- Does Independent Medical Review Participation Prevent Future Legal Action?
- Are Medical Records Kept Confidential in the Independent Medical Review Process?
- How Do I Request an Independent Medical Review from the California Department of Insurance?
- Health Insurance Terms and Phrases
Blue Shield allegation from DOI on Medical Necessity
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
- Your Medicare Coverage from medicare.gov
- Medicare Coverage Database which includes NCDs, LMRP/LCDs, as well as NCAs & CALs, from cms.hhs.gov
- Physician Fee Schedule lookup at cms.hhs.gov
- What is medical necessity? by Nancy W. Miller, as found in the Physician’s News Digest
- Defining Medical Necessity Under the Patient Protection and Affordable Care Act at academia.edu., by Daniel R. Skinner, published in the journal Public Administration Review (2013).
- Charles Martin, “Medical Use of Cannabis in Australia: ‘Medical necessity’ defences under current Australian law and avenues for reform” (2014) 21(4) Journal of Law and Medicine 875.
- Florida’s Medical Necessity Defense, Reconsidered by Miami attorney Jared H. Beck