Common use of Medically Necessary Clause in Contracts

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.

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- peer-reviewed medical literature generally recog- nized recognized by the relevant medical communitycommuni- ty; (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.

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 neces- sary treatments, procedures, services, or supplies sup- plies that the plan administrator or its designee determines, in the exercise of its dis- cretion discretion 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- peer-reviewed medical literature generally recog- nized recognized by the relevant medical communitycommuni- ty; (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.