NECESSARY AND APPROPRIATE. Services or supplies provided by a recognized health care Provider that We [or the Care Manager] Determine to be: necessary for the symptoms and diagnosis or treatment of the condition, Illness or Injury; provided for the diagnosis or the direct care and treatment of the condition, Illness or Injury; in accordance with generally accepted medical practice; not for a[Member]'s convenience; the most appropriate level of medical care that a [Member] needs; and furnished within the framework of generally accepted methods of medical management currently used in the United States. In the instance of an Emergency, the fact that a Non-Network Provider prescribes, orders, recommends or approves the care, the level of care, or the length of time care is to be received, does not make the services Medically Necessary and Appropriate. With respect to treatment of Substance Use Disorder the determination of Medically Necessary and Appropriate shall use an evidence-based and peer reviewed clinical review tool as designated in regulation by the Commissioner of Human Services.
NECESSARY AND APPROPRIATE. Services or supplies provided by a recognized health care Provider that We Determine to be: necessary for the symptoms and diagnosis or treatment of the condition, Illness or Injury; provided for the diagnosis or the direct care and treatment of the condition, Illness or Injury; in accordance with generally accepted medical practice; not for a[Member]'s convenience; the most appropriate level of medical care that a [Member] needs; and furnished within the framework of generally accepted methods of medical management currently used in the United States. In the instance of an Emergency, the fact that a Non-Network Provider prescribes, orders, recommends or approves the care, the level of care, or the length of time care is to be received, does not make the services Medically Necessary and Appropriate.
