Common use of Medical Necessity Clause in Contracts

Medical Necessity. Unless otherwise stated in this Agreement, the benefits of this Agreement are provided only for Services which are medically necessary. 1. Services which are medically necessary include only those which have been established as safe and effective, are furnished in accordance 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 effectively to the patient. 2. Hospital Inpatient Services which are medically necessary include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and which could not have been provided in a Physician's office, the Outpatient department of a Hospital, or another lesser facility without adversely affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hospitalization: a. for diagnostic studies that could have been provided on an Outpatient basis; b. for medical observation or evaluation;

Medical Necessity. Unless otherwise stated in this Agreement, the benefits of this Agreement are provided only for Services which are medically necessary.: 1. Services which are medically necessary include only those which have been established as safe and effective, are furnished in accordance with generally accepted professional standards to treat Sicknessillness, Accidental Injuryinjury, 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 effectively to the patient. 2. Hospital Inpatient Services which are medically necessary include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and which could not have been provided in a Physician's office, the Outpatient department of a Hospital, or another lesser facility without adversely affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hospitalization: a. for diagnostic studies that could have been provided on an Outpatient basis; b. for medical observation or evaluation;

Medical Necessity. Unless otherwise stated in this Agreement, the benefits of this Agreement are provided only for Services which are medically necessary. 1. Services which are medically necessary include only those which have been established as safe and effective, are furnished in accordance with generally accepted professional standards to treat Sickness, Accidental Injury, or medical condition, and which, as determined by Blue Shield, are: a. a) consistent with Blue Shield medical policy; and b. b) consistent with the symptoms or diagnosis; and c. c) not furnished primarily for the convenience of the patient, the attending Physician or other provider; and d. d) furnished at the most appropriate level which can be provided safely and effectively to the patient. 2. Hospital Inpatient Services which are medically necessary include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and which could not have been provided in a Physician's office, the Outpatient department of a Hospital, or another lesser facility without adversely affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hospitalization: a. a) for diagnostic studies that could have been provided on an Outpatient basis; b. ; 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 benefits of this Agreement are provided only for Services which are medically necessary. 1. Services which are medically necessary include only those which have been established as safe and effective, are furnished in accordance 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 effectively to the patient. 2. Hospital Inpatient Services which are medically necessary include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and which could not have been provided in a Physician's office, the Outpatient department of a Hospital, or another lesser facility without adversely affecting the patient's condition or the quality of medical care rendered. Inpatient Services which are not medically necessary include hospitalization: a. for diagnostic studies that could have been provided on an Outpatient basis; b. for medical observation or evaluation;