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}

CIGNA’s 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}   

Article on Medical Necessity at American Academy of Physicians Website

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}

Visit our HSA page for Federal Definition of Medical Expenses

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

External links

• 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

Kantor & Kantor Law Firm   

scott glovsky.com/medical-necessity-denials