Medical Policy
Subject: Medical Necessity Criteria
Document #: ADMIN.00004Publish Date: 07/07/2021
Status: ReviewedLast Review Date: 05/13/2021

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

05/13/2021

Medical Policy & Technology Assessment Committee (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

 

 


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.

© CPT Only – American Medical Association