Medical Necessity means just what?

When an Insurance Carrier processes a claim and denies for this does not meet Medical Necessity, what do they mean by that?

The term “Medically Necessary” or “Medical Necessity” is defined as a health care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are in accordance with generally accepted standards of medical practiced; clinically appropriate in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

Ultimately the medical record from the Physician or Healthcare Providers documented notes along with an appeal letter to specifically outline the reasons for Medical Necessity in regards to the patient’s case, are the only way to substantiate a case against a denial by an Insurance Company.  If the claim is still denied by the Insurance Company, you can attempt a 2nd or 3rd Level Appeal with the Medical Review Board.


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