Medically Necessary

This is a subpage of EBM Resources (parent page).

Medically necessary is defined by law. This definition, in turn, is incorporated into health plan documents and policies. In Minnesota (a fairly representative example), “medically necessary” or “medical necessity” means a health service that is consistent with the recipient’s diagnosis or condition and:

  • is recognized as the prevailing standard or current practice by the provider’s peer group; and
  • is rendered in response to a life threatening condition or pain; or to treat an injury, illness, or infection; or to treat a condition that could result in physical or mental disability; or to care for the mother and child through the maternity period; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition; or
  • is a preventive health service […]

PreferredOne (a Minnesota health plan) operationalizes this definition on Page 2 of its overarching medical policy. Medicare (the penultimate national carrier) has something similar here.

Medical necessity lives at the interface between law and medicine. Amy B. Monahan and Daniel Schwarcz, law professors at the University of Minnesota, published a deep dive in the Iowa Law Review.

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