A phrase used by insurance companies and 3rd party payers to describe the equipment and services a patient requires for health and safety needs. Insurance companies and 3rd party payers usually only provide equipment and services that meet medical needs, as opposed to educational or social needs.
Services/procedures which are approved in accordance with recognized medical standards as effective and appropriate and are essential to retard, reduce or eliminate an impairment.
Determination made by an insurance company that surgery is necessary to save your life, not necessarily just for your well-being.
Only those covered services, supplies and hospital admissions that are medically necessary are payable. Medically necessary services and supplies are those that are appropriate with regard to standards of good medical practice, appropriate to the illness or injury for which they are performed, not solely for the convenience of you or a provider, or the most appropriate supply or level of service that can be safely provided to you.
Means those services or supplies that are provided or prescribed by a Hospital or Physician which are essential for the symptoms, diagnosis, or treatment of the sickness or injury and are in accordance with standards of medical practice.
Under the Canada Health Act, the provincial and territorial governments are required to provide medically necessary hospital and physician services to their residents on a prepaid basis, and on uniform terms and conditions. The Act does not define medical necessity. The provincial and territorial health insurance plans, in consultation with their respective physician colleges or groups, are primarily responsible for determining which services are medically necessary for health insurance purposes. If it is determined that a service is medically necessary, the full cost of the service must be covered by public health insurance to be in compliance with the Act. If a service is not considered to be medically required, the province or territory need not cover it through its health insurance plan.
Criteria which determines whether services for diagnosis or treatment of illness or injury are essential and appropriate.
Health care services, supplies, or treatment that, in the judgment of the Health Care Provider, are appropriate and consistent with the diagnosis and, in accordance with generally accepted medical standards, cannot be omitted without adversely affecting the patient's condition or the quality of Medical Care rendered. The fact that a Physician has prescribed, recommended, approved, or supplied a treatment, service, or supply does not make it a medical necessity. All conditions are evaluated using the Plan's Cost Containment measures considering the views of the medical community, guidelines and practices of Medicare and Medicaid, and peer review literature. Health plans may exclude coverage for those conditions that are not deemed medically necessary.
refers to the determination that a specific health care service is: medically appropriate; necessary to meet a consumerâ€(tm)s health needs; consistent with the diagnosis; the most cost-effective option; and consistent with clinical standards of care. 47
Medical treatment is considered a medical necessity if it is appropriate for a member's condition. Periodically, we review a portion of claims to ensure our members receive care that is medically necessary.
Services and supplies that are (1) appropriate and necessary for the symptoms, diagnosis, or treatment of sickness or injury; (2) provided for the diagnosis or direct care or treatment of sickness or injury; (3) within the standards of good practice; (4) not primarily for the convenience of the plan member or provider; and (5) the most appropriate level of care that can safely be provided. Medical necessity can be interpreted restrictively to deny clinically appropriate services to address psychosocial problems of persons with addictive and mental disorders.
A term used when medical treatment is thought to be required by the prevailing medical consensus. What is medically necessary in one period or one area may not be so in another.
A determination that health care services provided are reasonable and necessary for the diagnosis or treatment of an illness.
Term use by insurers to describe medical treatment that is appropriate and rendered in accordance with generally accepted standards of medical practice.
An evaluation of health services to determine if they are medically appropriate and necessary to meet the needs of the member.
The decision by an MCO regarding the need for a particular clinical service. Historically, this term has sometimes been interpreted in an overly restrictive way that is insensitive to the full biopsychosocial nature of addiction treatment.
A plan may require that certain services, supplies or equipment meet a specified criteria to be covered.
Service or item that is considered Medically Necessary. Refer to Medically Necessary for definition. See: Scope of Care
A medical procedure or service must be performed only for the treatment of an accident, injury or illness and is not considered experimental, investigational or cosmetic. back to the top
A criterion that is determined by a claim analyst for medical treatments; provides that the prescribed medical procedure is one that (1) is considered effective and that is normally used for the specified illness or injury and (2) does not exceed in scope, duration, or intensity the level of care needed to provide safe, adequate and appropriate diagnosis or treatment.
Medical services or procedures performed only for the specific treatment of an injury or illness that is not considered experimental, investigational, or cosmetic in nature.
In order to be financed by an insurer, a service must be medically necessary.
A term given to the need that a specific service is deemed necessary to protect and promote an individual's Mental Health. This decision is made by a Doctor who after assessing an individual's presenting issues and needs decides that in order to remain healthy they require the specified service.
The determination that an applicant or participant meets the criteria for nursing home admission. Form 3652-a CARE is used to collect the information required to obtain the medical necessity determination. A medical necessity determination is effective for one year, and must be renewed annually to ensure a participant's continued eligibility.
Medical necessity is generally considered that which is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. The term clinical medical necessity is also used.