Medically Necessary/Medical Necessity

Medically Necessary/Medical Necessity means those services and supplies that are required for diagnosis or treatment of illness or injury and which, in the judgment of the utilization review manager, are:

  • Appropriate and consistent with the symptoms or diagnosis of the enrollee’s condition.
  • Appropriate with regard to standards of good medical practice in the area in which they are provided as supported by peer reviewed medical
  • Not primarily for the convenience of the enrollee or a physician or provider of services or
  • The least costly of the alternative supplies or levels of service that can be safely provided to the enrollee. This means, for example, that care rendered in a hospital inpatient setting is not medically necessary if it could have been provided in a less expensive setting, such as a skilled nursing facility, or by a nurse in the patient’s home without harm to the pa
  • Likely to enable the enrollee to make reasonable progress in treatment

Please Note: The fact that a physician or provider prescribes, orders, recommends or approves a service or supply does not, of itself, make the service medically necessary or a covered service.