Common use of Medical Necessity Clause in Contracts

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. Unless otherwise stated in the Agreement, the ben- efits benefits of this Agreement are provided only for Ser- vices Services 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 deter- mined by Blue Shield, are: a) consistent with Blue Shield medical policypoli- cy; and b) consistent with the symptoms or diagnosisdiagno- sis; and c) not furnished primarily for the convenience conven- ience of the patient, the attending Physician Physi- cian 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 HospitalHospi- tal, or another lesser facility without adversely af- fecting affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hos- pitalizationhospitalization: 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. Unless otherwise stated in the this Agreement, the ben- efits benefits of this Agreement are provided only for Ser- vices Services 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 deter- mined by Blue Shield, are: a) consistent with Blue Shield medical policypoli- cy; and b) consistent with the symptoms or diagnosisdiagno- sis; and c) not furnished primarily for the convenience conven- ience of the patient, the attending Physician Physi- cian 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 HospitalHospi- tal, or another lesser facility without adversely af- fecting affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hos- pitalizationhospitalization: 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. Unless otherwise stated in the this Agreement, the ben- efits benefits of this Agreement are provided only for Ser- vices Services 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 conditionconditions, and which, as determined deter- mined by Blue Shield, are: a) consistent with Blue Shield medical policypoli- cy; and b) consistent with the symptoms or diagnosisdiagno- sis; and c) not furnished primarily for the convenience conven- ience of the patient, the attending Physician Physi- cian, 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 HospitalHospi- tal, or another lesser facility without adversely af- fecting affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hos- pitalizationhospitalization: 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. Unless otherwise stated in this Agreement. the Agreement, the ben- efits benefits of this Agreement are provided only for Ser- vices Services 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 conditionconditions, and which, as determined deter- mined by Blue Shield, are: a) consistent with Blue Shield medical policypoli- cy; and b) consistent with the symptoms or diagnosisdiagno- sis; and c) not furnished primarily for the convenience conven- ience of the patient, the attending Physician Physi- cian, 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 HospitalHospi- tal, or another lesser facility without adversely af- fecting affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hos- pitalizationhospitalization: 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. Unless otherwise stated in the Agreement, the ben- efits benefits of this Agreement are provided only for Ser- vices Services 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 conditionconditions, and which, as determined deter- mined by Blue Shield, are: a) consistent with Blue Shield medical policypoli- cy; and b) consistent with the symptoms or diagnosisdiagno- sis; and c) not furnished primarily for the convenience conven- ience of the patient, the attending Physician Physi- cian, 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 HospitalHospi- tal, or another lesser facility without adversely af- fecting affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hos- pitalizationhospitalization: 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. Unless otherwise stated in the this Agreement, the ben- efits benefits of this Agreement are provided only for Ser- vices Services 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 deter- mined by Blue Shield, are: a) consistent with Blue Shield medical policypoli- cy; and b) consistent with the symptoms or diagnosisdiagno- sis; and c) not furnished primarily for the convenience conven- ience of the patient, the attending Physician Physi- cian, 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 HospitalHospi- tal, or another lesser facility without adversely af- fecting affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hos- pitalizationhospitalization: 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.