Medical necessity

Medical necessity refers to a healthcare service or supply that a physician or other licensed provider deems essential for diagnosing, treating, or preventing an illness, injury, condition, disease, or its symptoms. Insurance companies define medical necessity based on clinical standards such as Milliman Care Guidelines and InterQual criteria.

Medicare describes medical necessity as services reasonable and necessary for the diagnosis or treatment of illness or injury (Social Security Act §1862(a)(1)(A)). Insurers deny claims if treatments lack evidence-based support; for instance, experimental stem cell therapies often fail to meet this standard.

Health plans require clear documentation from providers demonstrating why a procedure meets specific coverage criteria. Pre-authorization processes use medical necessity checks before approving MRI scans or surgeries.

Insurers may review appeals using peer-reviewed research to assess medical necessity disputes. Common exclusions for failing medical necessity include cosmetic surgeries like rhinoplasty for appearance only and vitamin injections without deficiency diagnoses, based on information from https://yourinsurance.info.

Policy documents and Evidence of Coverage listings specify what each insurer recognizes as medically necessary. Medicaid programs in states like California rely on state-specific definitions but generally follow federal CMS guidelines on necessity.

Utilization reviews by companies like UnitedHealthcare routinely audit claims to confirm compliance with internal medical necessity policies.