Definitions for "Medically Necessary"
means those medical, surgical, services or supplies as determined by a Plan Provider in accordance with accepted medical and surgical practices and standards that are required to identify or treat a Member's medical condition or injury and which, as determined by the MagnaCare® Medical Director, are consistent with the symptoms or diagnosis and treatment of the Member's condition, disease, ailment or injury.
Health-care services and supplies are medically necessary when they are proper and necessary to diagnose and/or treat a medical condition and not merely used for the convenience of the physician or the patient.
Those services deemed essential to the preservation and maintenance of the health status of a patient in accordance with the standards of medical practice. What falls within the scope of medical necessity depends on who is answering the question (providers and utilization review personnel frequently come into conflict in this area).
Medical necessity must be established (via diagnostic and/or other information presented on the claim under consideration) before the carrier or insurer will make payment.
Items that are needed by the consumer for medical reasons. These items need to be ordered by a doctor or other medical professionals.