medically necessary


Also found in: Dictionary.
Related to medically necessary: medically necessary care

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
References in periodicals archive ?
On appeal, the majority of the Nova Scotia Court of Appeal rejected Kennedy C.J.S.C.'s narrow interpretation of medically necessary as requiring a "medical end." Instead, in the Court's view, the goal of medical treatment is simply to improve quality of life.
Any health care system, and certainly a national health care system, that is going to compete with rising health costs is going to have to include discussion of limits and cost/benefit analysis, a discussion anchored by the concept of "medically necessary."
A spokesman said: "It was becoming increasingly difficult for us to distinguish between medically necessary Caesarean sections and Caesarean sections that are a matter of personal or lifestyle choice.
Medically necessary health services are all those which physicians deem to be necessary for individual clients.
Although it's no page-turner, it contains references to all of the major tax credits and deductions that might be of use to you, including itemized deductions for medically necessary modifications to a home or vehicle and work-related accommodations.
Clear Coder offers doctors two ways to determine whether a treatment is considered medically necessary. By clicking on the CPT procedure code display, users can find all the diagnoses that can be treated with a specific procedure.
The suits specifically point to the insurers' "continual, arbitrary" denial of medically necessary care, "capricious" reductions in reimbursement claims, and denial of claims based on "arbitrary guidelines." They claim that the carriers--which control almost half the managed care contracts in New York--fail to provide adequate staffing to handle the volume of claims submitted, and that they provide physicians no information about how claims decisions are made.
Unscrupulous providers have long targeted nursing facilities and their residents, taking advantage of lax oversight to bill Medicare and Medicaid for services that are neither medically necessary nor medically performed.
In a fee for service system, doctors are paid every time they provide a service, so some may have the incentive to do more than what could be considered medically necessary in the delivery of patient care.
As the American Academy of Pediatrics reports, "Healthy, full-term infants should be given soy formula only when medically necessary." CONTACT: Physicians Committee for Responsible Medicine, 5100 Wisconsin Avenue, Suite 404, Washington, DC 20016/(202)686-2210); Center of Ethics and Toxics, PO Box 673, 39141 South Highway 1, Gualala, CA 95445/(707)884-1700; World Health Organization, 525 23rd Street NW, Washington, DC 20037-2895/ (202)974-3000; Baby Milk Action, 23 St.
By law, Medicare pays for medically necessary ambulance services only when other methods of transportation would endanger a beneficiary's health.
First they said that "although this procedure may be medically necessary; it is denied as a non-covered benefit of the plan." Later, they said it wasn't "medically necessary." The bottom line, HealthKeepers President Ellen C.

Full browser ?