Medical necessity definition

[participant3]

What is the definition of "Medical Necessity" as far as the review of prior authorization requests is concerned?

[participant2]

I've also been searching for the formal definition of medical necessity.

[gary.owens]

As for Medical Necessity there have been thousands of publications about this definition and depending on whose side you are on, the issue is very different. Stanford University developed a model definition a few years back. Here is a general definition that works well in most insurance contracts:

"Medically Necessary” or “Medical Necessity” shall mean health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:
a) in accordance with the generally accepted standards of medical practice;
b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
c) not primarily for the convenience of the patient or Physician, or other Physician, 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;
-the views of Physicians practicing in the relevant clinical area; and
-any other relevant factors.

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.