Medical Necessity. We Cover benefits described in this Contract as long as the dental service, procedure, treatment, test, device, or supply (collectively, “service”) is Medically Necessary e.g. orthodontia. The fact that a Provider has furnished, prescribed, ordered, recommended, or approved the service does not make it Medically Necessary or mean that We have to Cover it. We may base Our decision on a review of: • Your dental records; • Our dental policies and clinical guidelines; • Dental opinions of a professional society, peer review committee or other groups of Physicians; • Reports in peer-reviewed dental literature; • Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; • Professional standards of safety and effectiveness, which are generally-recognized in the United States for diagnosis, care, or treatment; • The opinion of health care professionals in the generally-recognized health specialty involved; • The opinion of the attending Providers, which have credence but do not overrule contrary opinions. Services will be deemed Medically Necessary only if: • They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease; • They are required for the direct care and treatment or management of that condition; • Your condition would be adversely affected if the services were not provided; • They are provided in accordance with generally-accepted standards of dental practice; • They are not primarily for the convenience of You, Your family, or Your Provider; • They are not more costly than an alternative service or sequence of services, that is at least as likely to produce equivalent therapeutic or diagnostic results; • When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. See the Utilization Review and External Appeal sections of this Contract for Your right to an internal Appeal and external appeal of Our determination that a service is not Medically Necessary.
Medical Necessity. In order for Health Care Services to be covered under this Contract, such services must meet all of the requirements to be a Covered Benefit or Covered Service, including being Medically Necessary, as defined by AvMed.
Medical Necessity. 6.1. CONTRACTOR will ensure that services provided are medically necessary in compliance with BHIN 21-073 and pursuant to Welfare and Institutions Code section 14184.402(a). Services provided to a client must be medically necessary and clinically appropriate to address the client’s presenting condition. Documentation in each client’s chart as a whole will demonstrate medical necessity as defined below, based on the client’s age at the time of service provision.
6.2. For individuals 21 years of age or older, a service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain as set forth in Welfare and Institutions Code section 14059.5.
6.3. For individuals under 21 years of age, a service is “medically necessary” or a “medical necessity” if the service meets the standards set forth in Section 1396d(r)(5) of Title 42 of the United States Code.
Medical Necessity. Unless otherwise stated in the Agreement, the ben- efits of this Agreement are provided only for Ser- vices which are medically necessary.
1. Services which are medically necessary in- clude only those which have been established as safe and effective, are furnished in accord- ance with generally accepted professional standards to treat Sickness, Accidental Injury, or medical condition, and which, as determined by Blue Shield, are:
a) consistent with Blue Shield medical policy; and
b) consistent with the symptoms or diagnosis; and
c) not furnished primarily for the convenience of the patient, the attending Physician or other provider; and
d) furnished at the most appropriate level which can be provided safely and effec- tively to the patient.
2. Hospital Inpatient Services which are medi- cally necessary include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and could not have been provided in a Physician's office, the Outpatient department of a Hospital, or another lesser facility without adversely af- fecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hos- pitalization:
a) for diagnostic studies that could have been provided on an Outpatient basis;
b) for medical observation or evaluation;
c) for personal comfort.
3. Blue Shield reserves the right, at its option, to waive this provision.
Medical Necessity. As defined in Hawaii Revised Statutes (“HRS”) 432E-1.4, for health interventions that the health plans are required to cover within the specified categories, a health intervention is medically necessary if it is recommended by the treating physician or treating licensed health care provider, is approved by health plan’s medical director or physician designee, and is:
(i) For the purpose of treating a medical condition;
(ii) The most appropriate delivery or level of service, considering potential benefits and xxxxx to the patient;
(iii) Known to be effective in improving health outcomes; provided that:
a. Effectiveness is determined first by scientific evidence;
b. If no scientific evidence exists, then by professional standards of care; and
c. If no professional standards of care exist or if they exist but are outdated or contradictory, then by expert opinion; and
(iv) Cost-effective for the medical condition being treated compared to alternative health interventions, including no intervention. For purposes of this paragraph, cost-effective shall not necessarily mean the lowest price. For purposes of this Section:
Medical Necessity. The definition of medical necessity for Medicaid services is included in the Michigan Medicaid Provider Manual: Mental Health –Substance Abuse section.
Medical Necessity. 4.5.4.1 Based upon generally accepted medical practices in light of Conditions at the time of treatment, Medically Necessary services are those that are: · Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Member’s medical Condition; · Compatible with the standards of acceptable medical practice in the community; · Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms; · Not provided solely for the convenience of the Member or the convenience of the Health Care Provider or hospital; and · Not primarily custodial care unless custodial care is a covered service or benefit under the Members evidence of coverage.
4.5.4.2 There must be no other effective and more conservative or substantially less costly treatment, service and setting available.
4.5.4.3 For children under 21, the Contractor is required to provide medically necessary services to correct or ameliorate physical and behavioral health disorders, a defect, or a condition identified in an EPSDT (Health Check) screening, regardless whether those services are included in the State Plan, but are otherwise allowed pursuant to 1905 (a) of the Social Security Act. See Diagnostic and Treatment, Section 4.7.5.2.
Medical Necessity. 18.4.1 Pursuant to BHIN 24-001 and consistent with Welfare & Institutions Code § 14059.5, DMC-ODS services must be medically necessary.
Medical Necessity. The Utilization Management (UM) program, processes and timeframes shall be in accordance with 00 XXX 000, 00 XXX 000, 00 XXX 438 and the private review agent requirements of KRS 304.17A as applicable. The Contractor shall have a comprehensive UM program that reviews services for Medical Necessity and that monitors and evaluates on an ongoing basis the appropriateness of care and services for physical and behavioral health. A written description of the UM program shall outline the program structure and include a clear definition of authority and accountability for all activities between the Contractor and entities to which the Contractor delegates UM activities. The description shall include the scope of the program; the processes and information sources used to determine service coverage; clinical necessity, appropriateness and effectiveness; policies and procedures to evaluate care coordination, discharge criteria, site of services, levels of care, triage decisions and cultural competence of care delivery; processes to review, approve and deny services, as needed, particularly but not limited to the EPSDT program. The UM program shall be evaluated annually, including an evaluation of clinical and service outcomes. The UM program evaluation along with any changes to the UM program as a result of the evaluation findings, will be reviewed and approved annually by the Medical Director, the Behavioral Health Director, or the Medicaid Commissioner.
Medical Necessity. Based upon generally accepted medical practices in light of conditions at the time of treatment, Medically Necessary services are those that relate to the prevention, diagnosis, and treatment of health impairments, or to the ability to achieve age-appropriate growth and development and the ability to attain, maintain, or regain functional capacity, and are:
7.2.1 Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Enrollee’s medical condition;
7.2.2 Compatible with the standards of acceptable medical practice in the community;
7.2.3 Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;
7.2.4 Not provided solely for the convenience of the Enrollee or the convenience of the Provider; and
7.2.5 Not primarily custodial care (for example, xxxxxx care).
