Medical Policy

 

Subject: Medical Necessity Criteria
Document #: ADMIN.00004 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

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

07/26/2018

Medical Policy & Technology Assessment Committee (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