Common use of Medical Necessity Clause in Contracts

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. 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.