What does “medically necessary”, “medical necessity” & IMR mean?

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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} 

Prior Authorization 

Misc.   Links & News

• Her spine surgery was denied. Doctors say it’s all too common.
  Insurance denied 18-year-old Nala White’s surgery for degenerative disc disease. After NBC News reached out, it was approved the next day.  NBC 8/2025
•   Democrats introduce bill to repeal Medicare prior authorization pilot
  The lawmakers argue the CMS innovation center model, which will implement AI-backed prior authorization for some services in six states, will add red tape and limit access to care.  Health Care Dive  10.2025 * 

Clinical Guidelines

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

IMR Independent Medical Review 

Visit our webpage on Knee & Hip Replacement