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Medical Necessity

Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.

Health insurance companies provide coverage only for health-related serves that they define or determine to be medically necessary. Medicare, for example, defines medically necessary as: “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.”

Medical Necessity

Definition of Medical Necessity: Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Other countries may have medical doctrines or legal rules covering broadly similar grounds. The term clinical medical necessity is also used.

Coverage for Care:  Implementation of Medicare Guides

Medical Necessity

Medicare pays for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."  (click here for more Medicare information

Medicare has a number of policies that describe coverage criteria.  In a very few cases, Medicare may determine coverage should be based on individual cases and not general acceptance. Even in individual cases of services being deemed "reasonable and necessary," coverage may be limited due to Medicare coverage policies for frequency.

Passport health can help with 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

- Medical Necessity Definitions
- More Medical Necessity Information

Medical Necessity Blog Post of the Month

March 2, 2012

Exclusion of Medical Necessity Defense to Charge of Failing to Report to BOP Upheld

by Shari Allison

The 10th upholds the refusal to admit evidence to support a medical necessity defense to a charge of failure to report to BOP following sentencing. (Full Story)

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