medically necessary

(redirected from Medically necessary, criteria)

medically necessary

A covered health service or treatment that is mandatory to protect and enhance the health status of a patient, and could adversely affect the patient’s condition if omitted, in accordance with accepted standards of medical practice.

When applied to hospitalisation, medically necessary means that a plan member’s acute care needs are such that he or she cannot receive safe and adequate care as an outpatient or at a lower level of care.

Medically necessary, criteria 
A. Appropriate for the symptoms and diagnosis or treatment of a condition, illness or injury.
B. Provides for the diagnosis or direct care and treatment of the condition, illness or injury.
C. In accordance with the standards of good medical practice in the service area.
D. Not primarily for the convenience of a plan member or a plan provider. 
E. The most appropriate level or type of service or supply that can safely be provided to the plan member.

medically necessary

Managed care adjective Referring to a covered service or treatment that is absolutely necessary to protect and enhance the health status of a Pt, and could adversely affect the Pt's condition if omitted, in accordance with accepted standards of medical practice. See Futility.
Medically necessary, criteria  
a. Appropriate for the Sx and diagnosis or treatment of a condition, illness or injury
b. Provided for the diagnosis or the direct care and treatment of the condition, illness or injury
c. In accordance with the standards of good medical practice in the service area
d. Not primarily for the convenience of a plan member or a plan provider
e. The most appropriate level or type of service or supply which can safely be provided to the plan member

med·i·cal·ly ne·ces·sary

(med'i-kăl-ē nes'ĕ-sar-ē)
Services or supplies needed for diagnosis, treatment, or care.

Patient discussion about medically necessary

Q. is it ok to use drugs for medical reasons? and who is to decide when is necessary to use drugs when needed?

A. Today the most used "medical" drugs are narcotics- for pain relief, for patients who suffer extreme pain. All sorts of Codaine and Morphine types are used and on a very wide basis, and they are specially perscribed for ones who need them.

More discussions about medically necessary
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