Services or supplies which meet the following conditions: Are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition; Are provided for the diagnosis or direct care and treatment of medical conditions; Meet professionally recognized standards of practice at the time of treatment; Are not primarily for the convenience of the patient or provider; Are at the most appropriate level or supply of service that can safely be provided.
Term relating to an evaluation process used by insurance companies to decide whether requested health care services will be covered.
This is a common phrase used in a peculiar way by medical insurance companies and which results in great confusion. When an insurance company uses the word “necessary” they indicate that they are willing to pay. If they say “not necessary” they mean that they will not pay. It has nothing to do with a patient's need for a treatment. For example, an insurance denial form may use the abbreviation, “MED PROC NOT NEC” to indicate that they have decided that the procedure is “not necessary” for the patient, and that they do not wish to pay for any charges.
Health insurers often specify that, in order to be covered, a treatment or drug must be medically necessary for the consumer. Anything that falls outside of the realm of medical necessity is usually not covered. The plan will use prior authorization and utilization management procedures to determine whether or not the term "medically necessary" is applicable.
Services or supplies that UNICARE determines to be: Appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition Provided for the diagnosis or direct care and treatment of the medical condition Within the standard of good medical practice within the organized medical community Not primarily for the convenience of the member, the member's physician, or any other health care professional The most appropriate supply or level of service that can safely be provided Note: The definition of medically necessary in the Member's benefit agreement, or required by state law, supersedes this definition.
Considered necessary by a physician to treat a medical condition and not to include preventive care or elective services unless otherwise covered by an insurance policy.
Services or supplies which meet the following tests: They are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition. They are provided for the diagnosis or direct care and treatment of the medical condition. They meet the standards of good medical practice within the medical community in the service area. They are not primarily for the convenience of the plan member or a plan provider. They are the most appropriate level or supply of service which can safely be provided.
the usual and customary expense incurred upon the recommendation and approval of a physician for the medical services and supplies generally furnished for cases of comparable nature and severity in the particular geographical area concerned. Any agreement as to fees or charges made between the individual and the physician shall not bind the Plan in determining its liability with respect to necessary expenses. These incurred expenses must be: a. consistent with the symptoms of diagnosis and treatment of the condition, Illness, or Injury; b. appropriate with regard to standards of good medical practice; c. not primarily for the convenience of the patient, the physician or other provider; d. the most appropriate level of services which can safely be provided to the patient. When applied to an inpatient, it - that the patient's medical symptoms or conditions require that the services or supplies cannot be safely provided to the patient as an outpatient.
The determination on whether your prescribed treatment is appropriate for your condition.
The level of services and supplies (frequency, extent and type) that is adequate for the diagnosis and treatment of illness or injury. Medical necessity includes the concept of appropriate medical care.
A term used to refer to the medical services which are required for proper treatment of an illness.
Each health care plan determines if a service is medically necessary for the diagnosis of the treatment of an injury or illness. This determination is based on such standards as: The service is appropriate and required. The service is safe and effective according to accepted clinical evidence. There is no less intensive or more appropriate diagnostic or treatment alternative. If the plan determines that a service is not medically necessary, you pay the entire cost.
A term given to medical procedures or services that are performed only for the treatment of an accident, injury, or illness which are appropriate for the diagnosis and are not considered experimental, investigational, or cosmetic.
Those covered services provided by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law to: Prevent disease, disability and other adverse health conditions or their progression, or Prolong life.
Medically necessary services are services that are deemed as necessary to treat a condition, illness, etc by the generally accepted standards of medical practice. These services are usually determined as medically necessary by your PCP.
Treatments or services an insurance policy will pay for as defined in the contract.
In general, services or supplies that meet the medical necessity criteria of the claims administrator. See "Medically Necessary" for a detailed definition.
Services or supplies that meet the following: (1) they are appropriate and necessary for symptoms, diagnosis, or treatment of the medical condition; (2) they are provided for the diagnosis or direct care and treatment of medical conditions; (3) they meet the standards of good medical practice within the medical community in the service area: (4) they are primarily for the convenience of the patient or provider; (5) they are the most appropriate level or supply of service that can safely be provided.
Procedures, treatment, supplies, equipment or services determined to be: Appropriate for the symptoms, diagnosis or treatment of a medical condition; and Provided for the diagnosis or direct care and treatment of the medical condition; and Within generally accepted standards of good medical practice; and Not primarily for the convenience of the member or the memberâ€(tm)s provider; and The most appropriate procedure, treatment, supply, equipment or level of service which can safely be provided. Medical necessity does not guarantee payment.
Services or supplies which, under the provisions of this agreement, are determined to be: Appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition. Provided for in the diagnosis or direct care and treatment of the medical condition. Within standards of good medical practice within organized medical community. Not generally regarded as experimental, investigative, or unproved by recognized medical professionals and appropriate governmental agencies. Not primarily for the convenience of the member, the member's physician, or any other practitioner or health care professional. The most appropriate supply or level of service that can safely be provided. For inpatient hospital stays, this means that acute care is necessary due to the types of services the member is receiving or the severity of the member's condition, and safe and adequate care cannot be received in an outpatient or other less intensified medical setting. In the case that this meaning conflicts with an applicable law or regulation, such law or regulation shall control.
care and treatment is recommended or approved by a Physician; is consistent with the patient's condition or accepted standards of good medical practice; is medically proven to be effective treatment of the condition; is not performed mainly for the convenience of the patient or provider of medical services; is not conducted for research purposes; and is the most appropriate level of services which can be safely provided to the patient. All of these criteria must be met; merely because a Physician recommends or approves certain care does not mean that it is Medically Necessary. The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary.
A medical procedure or treatment that is needed to treat a problem identified by your doctor.
MagnaCare regards services, supplies or equipment provided by a hospital or covered provider of health services as medically necessary if MagnaCare determines that they are: Consistent with the symptoms or diagnosis and treatment of the patient's condition, illness or injury; in accordance with standards of good medical practice; not solely for the convenience of the patient, the family, or the provider; not primarily custodial; and the most appropriate level of service for the patient's safety. The fact that a covered provider may have prescribed, recommended, or approved a service, supply, or equipment does not, in itself, make it medically necessary.
Treatments or services a health care policy/contract will pay for as defined in the contract. Each policy/contract should define medically necessary.
Services and supplies, including tests and examinations, that are consistent with generally accepted practices for the diagnosis of an illness or injury, or the medical care of a diagnosed illness or injury. Only medically necessary services and supplies, as determined by the PPO or HMO, are covered by the plan.
Behavioral health services which have been established in accordance with generally accepted professional standards and determined by PacifiCare Behavioral Health's Utilization Review Committee to be: Necessary for the treatment or diagnosis of a moderate to severe mental disorder as defined by the DSM-IV or chemical dependency. Appropriate for the severity of symptoms, consistent with the diagnosis, and otherwise in accordance with generally accepted medical and behavioral health practice and professionally recognized standards. Not furnished primarily for the convenience of the member, the attending physician or other provider of service. Furnished at the most appropriate level which may be provided safely and effectively to the member. Designed to diminish the member’s acute symptoms, render emotional support and stabilize the member’s condition in the short term.
Services or supplies that: are proper and needed for the diagnosis, or treatment of the client's medical condition; are provided for the diagnosis, direct care, and treatment of the client's medical condition, meet the standards of good medical practice in the local area; and are not mainly for the convenience of the client or doctor.
Medical services that are appropriate and necessary to meet the basic health needs of patients and that are not related to cosmetic procedures or lifestyle preferences. National medical practice guidelines are used to determine medical necessity.
A covered procedure, service, or supply that is considered eligible for benefits under this plan. All covered services must be medically necessary.
Health care services or supplies that are appropriate for a particular sickness or injury. To be considered medically necessary, a health care service or item must be consistent with the symptoms and treatment of the injury or sickness. It also needs to be within the standards of good medical practice in the area, and the most appropriate level of care that can be provided to you safely. Also, medically necessary services cannot be solely for your convenience or the convenience of a doctor or hospital.
Determination by a health care provider that the physical or mental condition of a patient warrants a certain type of medical care.
Care or services required to identify or treat a covered person’s illness or injury that are provided for the diagnosis or care and treatment of a medical condition, appropriate and necessary for the symptoms, diagnosis or treatment of a medical condition.
A medical service or Treatment which in the opinion of a qualified Medical Practitioner is appropriate and consistent with the diagnosis and which in accordance with generally accepted medical standards could not have been omitted without adversely affecting the Insured Persons condition or the quality of medical care rendered.
Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition; are used for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of you or your doctor.
Generally, a medical service or supply which is considered appropriate for a patient's condition and consistent with his or her diagnosis and which complies with currently accepted medical standards.
Procedures, services, or equipment that meet good medical standards and are necessary for the diagnosis and treatment of a medical condition.
A term used to describe a healthcare service or treatment, which in the judgment of the Plan: Is appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Louisiana, could not have been omitted without adversely affecting the patient's condition or the quality of health services rendered; Is required for reasons other than the convenience of the Member or his or her Physician or solely for Custodial Care, comfort, convenience, appearance, educational, recreational, vocational or maintenance reasons; Is performed in the most appropriate manner in terms of treatment methods, setting, frequency and intensity, taking into consideration the Member's medical condition and type of setting appropriate for the condition; and As to inpatient care or institution, could not have been provided in a Physician's office, the outpatient department of a Hospital or a non-residential Facility without adversely affecting the patient's condition or quality of health services rendered.
Services required to prevent harm to the patient or an adverse effect on the patient's quality of life. The term is usually used to determine whether or not a procedure or service is covered by insurance.
Confinement, care or treatment which: - Is appropriate with the diagnosis in accordance with accepted standards of practice. - Cannot be omitted without adversely affecting the insured's condition.
evaluation of health care services to determine if they are medically appropriate and required to meet basic health needs. The medical necessity must be consistent with the diagnosis or condition and rendered in a cost-effective manner and consistent with national medical practice guidelines regarding type, frequency and duration of treatment.
A term used by insurance companies and health plans to describe care that is appropriate and provided according to general standards of medical care.
A service or treatment which is appropriate and consistent with diagnosis, and which, in accordance with accepted standards of practice in the medical community of the area in which the health services are rendered, could not have been omitted without adversely affecting the member's condition or the quality of medical care rendered.
A term describing a requested medical service that is determined necessary because there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. " Course of treatment" may include mere observation or, where appropriate, no treatment at all. See: Scope of Care
The reasonable and appropriate diagnosis, treatment and followup care as determined and prescribed by qualified, appropriate health care providers in treating a condition, illness or disease.
This phrase is used to describe medical treatment given in accordance with generally accepted standards of medical practice.
To evaluate services to determine if they are medically appropriate, consistent with diagnosis, cost effective, and accepted as standard care within the medical community.
Health care service or treatment that is generally accepted in medical practice as being needed for the diagnosis or treatment of a patient's condition and that cannot be omitted without harming the patient--as judged against generally accepted standards of medical practice.
Applies to those patients who need contact lenses due to medical situations/conditions.
Services or supplies that are considered by Medicare to be appropriate and needed for treatment.
Services or supplies that are deemed 'necessary' for your diagnosis and treatment, meet standards of good medical practice, and are not primarily for convenience.
The benefits of a Plan are provided only for services that are Medically Necessary as determined by Pinnacle. The services must be ordered by the attending Physician for the direct care and treatment of a covered illness, injury or condition. The services must be standard medical practice where received for the illness, injury or condition being treated and must be legal in the United States.
No matter what type of health insurance you choose, your health plan will examine the medical necessity of the care you receive. Insurers will decide, based on your illness or injuries, if the care you received was needed and if it followed accepted medical practice. Care that is found not to be medically necessary may not be paid for by your insurer.
Medical services or supplies that: are proper and needed for the diagnosis or treatment of a patient’s medical condition; are provided for the diagnosis, direct care, and treatment of a patient’s medical condition; meet the standards of good medical practice in the area; and are not chosen mainly for the convenience of the patient or doctor.
Treatment that, if it were omitted, would negatively affect the patient's life.
Many insurance policies will pay only for treatment that is deemed "medically necessary" to restore a persons health. For instance, many policies will not cover routine physical exams or plastic surgery for cosmetic purposes.
A drug, device, procedure, treatment plan, or other therapy that is covered under your health insurance policy and that your doctor, hospital, or provider has determined essential for your medical well-being, specific illness, or underlying condition.
Services or supplies which are necessary for the symptoms, diagnosis, or treatment of a medical condition. They meet the standards of appropriate medical practice within the medical community in your service area and are not primarily carried out for your convenience or your doctor's.
A service or treatment which is absolutely necessary in treating a patient and which could adversely affect the patient's condition if it were omitted.