Medical Policy |
Subject: Medical Necessity Criteria | |
Document #: ADMIN.00004 | Publish Date: 06/28/2023 |
Status: Reviewed | Last Review Date: 05/11/2023 |
THESE CRITERIA ARE USED IN THE DEVELOPMENT AND UPDATING OF MEDICAL POLICIES AND CLINICAL UM GUIDELINES. AS THESE CRITERIA MAY NOT BE THE CRITERIA USED IN THE DEFINITION OF MEDICAL NECESSITY WITHIN THE COVERED INDIVIDUAL’S PLAN DOCUMENT, THE DEFINITION IN THE COVERED INDIVIDUAL’S PLAN DOCUMENT IS TO BE USED FOR BENEFIT DETERMINATIONS (SEE COVERED INDIVIDUAL’S BENEFIT PLAN FOR SPECIFIC CONTRACT LANGUAGE).
Definitions |
"Medically Necessary" services are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a covered individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.
Index |
Medical Necessity
Medical Necessity Criteria
Medically Necessary
Document History |
Status | Date | Action |
Reviewed | 05/11/2023 | Medical Policy & Technology Assessment Committee (MPTAC) review. |
Reviewed | 05/12/2022 | MPTAC review. |
Reviewed | 05/13/2021 | MPTAC review. |
Reviewed | 05/14/2020 | MPTAC review. |
Reviewed | 06/06/2019 | MPTAC review. |
Reviewed | 07/26/2018 | MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” |
Reviewed | 08/03/2017 | MPTAC review. |
Reviewed | 08/04/2016 | MPTAC review. |
Reviewed | 08/06/2015 | MPTAC review. |
Revised | 08/14/2014 | MPTAC review. Clarification to header. |
Reviewed | 08/08/2013 | MPTAC review. |
Reviewed | 08/09/2012 | MPTAC review. |
Revised | 08/18/2011 | MPTAC review. Clarification to header. |
Reviewed | 08/19/2010 | MPTAC review. Changed title to Medical Necessity Criteria. Index updated. |
| 05/27/2010 | Clarification to header. |
Revised | 08/27/2009 | MPTAC review. |
Reviewed | 11/20/2008 | MPTAC review. |
Reviewed | 11/29/2007 | MPTAC review. |
Reviewed | 12/07/2006 | MPTAC review. No change to position. |
Revised | 12/01/2005 | MPTAC review. |
Pre-Merger Organizations | Last Review Date | Document Number | Title |
Anthem, Inc. | N/A | N/A | Definition: Medically Necessary or Medical Necessity |
WellPoint Health Networks, Inc. | 09/22/2005 | Definitions ii | Definition: Medically Necessary |