THESE CRITERIA ARE ONLY TO BE USED IN THE DEVELOPMENT AND UPDATING OF MEDICAL POLICIES AND CLINICAL GUIDELINES. ALTHOUGH A SERVICE MAY BE DETERMINED TO BE MEDICALLY NECESSARY BASED ON A POLICY OR GUIDELINE DEVELOPED IN ACCORDANCE WITH THIS DEFINITION, THERE MAY NOT BE BENEFITS FOR THE SERVICE UNDER THE COVERED INDIVIDUAL'S BENEFIT PLAN (SEE COVERED INDIVIDUAL'S BENEFIT PLAN FOR SPECIFIC CONTRACT LANGUAGE.)

"Medically Necessary" services are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

• in accordance with generally accepted standards of medical practice; and
• clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the covered individual's illness, injury or disease; and
• not primarily for the convenience of the covered individual, physician or other health care provider; 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 covered individual'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, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.  

Medical Necessity
Medical Necessity Criteria
Medically Necessary