Medically Necessary. In general, We will not Cover any dental service, procedure, treatment, test or device that We determine is not Medically Necessary. If an External Appeal Agent certified by the State overturns Our denial, however, We will Cover the service, procedure, treatment, test or device for which coverage has been denied, to the extent that such service, procedure, treatment, test or device, is otherwise Covered under the terms of this Contract.
Medically Necessary. (MEDICAL NECESSITY) means that the healthcare services provided to treat your illness or injury, upon review by BCBSRI are: • appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • not primarily for the convenience of the member, the member’s family or provider of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether a healthcare service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section
Medically Necessary. (MEDICAL NECESSITY) means that the orthodontic services provided to treat your illness or injury, upon review by BCBSRI are: • appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • not primarily for the convenience of the member, the member’s family or provider of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether the orthodontic service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section 5. We review medical necessity on a case-by-case basis. The fact that your dentist performed or prescribed a procedure or treatment does not mean that it is medically necessary. We determine medical necessity solely for purpose of claims payment under this plan.
Medically Necessary. Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which - is required for the medical management of the illness or injury suffered by the insured; - must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity; - must have been prescribed by a medical practitioner, - must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
Medically Necessary or Medical Necessity means the use of any appropriate medical treatment, service, equipment and/or supply as provided by a Hospital, Skilled Nursing Facility, Physician or other provider which is necessary, as determined by AvMed, for the diagnosis, care or treatment of a Member's illness or injury and which is:
a. consistent with the symptoms, diagnosis and treatment of the Member's Condition;
b. the most appropriate level of supply and/or service for the diagnosis and treatment of the Member's Condition;
c. in accordance with standards of acceptable community practice;
d. not primarily intended for the personal comfort or convenience of the Member, the Member's family, the Physician or other Health Professionals;
e. approved by the appropriate medical body or health care specialty involved as effective, appropriate, and essential for the care and treatment of the Member's Condition; and f. not Experimental or Investigational.
Medically Necessary. See the How Your Coverage Works section of this Contract for the definition. Medicare: Title XVIII of the Social Security Act, as amended. Member: The Subscriber or a covered Dependent for whom required Premiums have been paid. Whenever a Member is required to provide a notice, “Member” also means the Member’s designee. New York State of Health (“NYSOH”): The New York State of Health, the Official Health Plan Marketplace. The NYSOH is a marketplace where individuals, families and small businesses can learn about their health insurance options; compare plans based on cost, benefits and other important features; apply for and receive financial help with premiums and cost-sharing based on income; choose a plan; and enroll in coverage. The NYSOH also helps eligible consumers enroll in other programs, including Medicaid, Child Health Plus, and the Essential Plan. Non-Participating Provider: A Provider who doesn’t have a contract with Us to provide services to You. You will pay more to see a Non-Participating Provider. Out-of-Network Coinsurance: Your share of the costs of a Covered Service calculated as a percent of the Allowed Amount for the service that You are required to pay to a Non-Participating Provider. The amount can vary by the type of Covered Service. Out-of-Network Copayment: A fixed amount You pay directly to a Non-Participating Provider for a Covered Service when You receive the service. The amount can vary by the type of Covered Service. Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We begin to pay 100% of the Allowed Amount for Covered Services. This limit never includes Your Premium, Balance Billing charges or the cost of dental care services We do not Cover. The Out-of-Pocket Limit only applies to benefits that are part of the pediatric dental essential health benefit.
Medically Necessary. Shall be defined by Tennessee Code Annotated, Section 71-5-144, and shall describe a medical item or service that meets the criteria set forth in that statute. The term “medically necessary”, as defined by Tennessee Code Annotated, Section 71-5- 144, applies to TennCare enrollees. Implementation of the term “medically necessary” is provided for in regulations at 1200-13-16, consistent with the statutory provisions, which control in case of ambiguity. No enrollee shall be entitled to receive and TennCare shall not be required to pay for any items or services that fail fully to satisfy all criteria of “medically necessary” items or services, as defined either in the statute or in regulations at 1200-13-16.
Medically Necessary or Medical Necessity means the use of any appropriate medical treatment, service, equipment and/or supply as provided by a Health Care Provider which is necessary, as determined by AvMed, for the diagnosis, care or treatment of a Member's Condition and which is:
a. consistent with the symptoms, diagnosis and treatment of the Member's Condition;
b. the most appropriate level of supply and/or service for the diagnosis and treatment of the Member's Condition;
c. in accordance with standards of acceptable community practice;
d. not primarily intended for the personal comfort or convenience of the Member, the Member's family, the Physician or other Health Professionals;
e. approved by the appropriate medical body or health care specialty involved as effective, appropriate, and essential for the care and treatment of the Member's Condition; and f. not Experimental or Investigational.
Medically Necessary. Services, medicines, or supplies that are necessary and appropriate for the diagnosis or treatment of an Enrollee’s illness, injury, or medical condition according to accepted standards of medical practice and that are not provided only as a convenience.
Medically Necessary. The fact that a provider has performed, prescribed, recom- mended, ordered, or approved a treatment, procedure, service, or supply; or that it is the only available treatment, procedure, service, or supply for a condition, does not, in itself, determine medical necessity. Medically nec- xxxxxx treatments, procedures, services, or supplies that the plan administrator or its designee determines, in the exercise of its dis- cretion are—
(A) Expected to be of clear clinical benefit to the member;
(B) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for a member’s illness, injury, mental illness, substance use disorder, disease, or its symptoms;
(C) In accordance with generally accepted standards of medical practice that are based on credible scientific evidence published in peer- reviewed medical literature generally recog- nized by the relevant medical community;
(D) Not primarily for member or provider convenience; and
(E) Not more costly than an alternative service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of member’s illness, injury, disease, or symp- toms.
