medical necessity


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medical necessity

FDA-speak
A product is considered medically necessary, or to be a medical necessity, if it is used to treat or prevent a serious disease or medical condition, and if there is no other available source of that product or alternative drug or therapy judged by medical staff to be an adequate substitute. Patient "inconvenience" alone is an insufficient basis to classify a product as a medical necessity.

Managed care
The use of diagnosis codes to establish necessary preconditions for providing a service.
 
Medspeak
A general term referring to diagnostic procedures needed to detect a potentially treatable condition, or therapeutic modalities required by a particular condition.
Segen's Medical Dictionary. © 2012 Farlex, Inc. All rights reserved.

medical necessity

Medical practice A general term referring to diagnostic procedures needed to detect a potentially treatable condition, or therapeutic modalities required by a particular condition
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.
References in periodicals archive ?
CMS officials advise hospitals to use certified coders who are up-to-date on current practice, to implement internal quality reviews of their own cases for billing accuracy and correct medical necessity documentation, and to respond within the 45-day deadline.
Configuration can be completed in a matter of days for registration data validation and editing; eligibility verification; authorization checking and completion; financial screening; medical necessity screening; patient payment responsibility calculation; and denials management reporting and account resolution.
The federal court found that, to promote its own bottom line, UBH denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral health care.
Of that, 91.2 percent was due to missing documentation and only 0.3 percent was due to the beneficiary not meeting the medical necessity requirements.
Lack of medical necessity is a defense to an action to recover no-fault benefits, which an insurer may assert upon a timely denial, based either on a medical examination or a peer review report.
The Texas Division of Workers' Compensation (DWC) drafted the rule to stop prescribers from continuing to exploit a loophole in the state workers' compensation drug formulary, one that allowed compound prescriptions to be filled without first obtaining preauthorization to confirm medical necessity for the injured worker.
[E]xternal-review decisions are independent determinations of medical necessity that do not supersede contractual definitions of medical necessity, wrote Justice Natalie Hudson for the court.
A district court in Washington, DC, has held that alleging a laboratory's failure to independently verify the medical necessity of tests ordered by treating physicians is sufficient to survive a Rule 12(b) challenge to a federal False Claims Act claim.
In the MHPAEA medical necessity criteria disclosure section, the officials take questions involving patients with anorexia who are trying to get health plans to cover their care.
Contract terms that involve medical necessity also can lead to frustration if not properly negotiated.
There was no medical necessity for emergency cesarean delivery.

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