Medical Policy



Subject: Medical Necessity Criteria
Document #: ADMIN.00004 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

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 08/03/2017 Medical Policy & Technology Assessment Committee (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