ADMIN.00004 Medical Necessity Criteria

Medical Policy

Subject: Medical Necessity Criteria
Document #: ADMIN.00004	Publish Date: 06/28/2024
Status: Reviewed	Last Review Date: 05/09/2024

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:

in accordance with generally accepted standards of medical practice; and
clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the covered individual’s illness, injury or disease; and
not primarily for the convenience of the covered individual, physician or other health care provider; 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 covered individual's illness, injury or disease.

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	05/09/2024	Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed	05/11/2023	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

Definition: Medically Necessary or Medical Necessity

WellPoint Health Networks, Inc.

09/22/2005

Definitions ii

Definition: Medically Necessary

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.