Medical necessity
Standard for determining appropriateness of a service.
Definitions (4)
The clinical standard used to determine whether healthcare services are appropriate and required for a patient's condition; denials based on medical necessity trigger the requirement that a licensed Arizona medical director review and sign the written denial.
Healthcare services or supplies that are determined to be reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member.
Medical necessity refers to healthcare services or items that are reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. CMS regulations require MA plans to base coverage decisions on medical necessity.
The determination that a health care service is appropriate and required for the enrollee's clinical circumstances.
Related Terms
Prior authorization
Insurer approval required before certain services are covered....
Written denial
Documented denial including explanation and physician signature....
Medical director
Arizona-licensed physician who reviews and signs denials....
Minimum Necessary
Limiting PHI access to what is needed for the purpose....
clinical safety
Systematic management of risks that could cause patient harm....