Medically Necessary Services are services required to:
diagnose or prevent an illness, injury or condition
treat an illness, injury, or condition
keep condition from getting worse
lessen pain or severity of condition
help improve condition
restore lost skills (rehabilitation)
Medically Necessary Services…
are consistent with diagnosis;
meet accepted standards of good medical practice;
can be safely provided.
HMO clinicians may review a PCP’s proposed course of treatment to determine medical necessity
Medically Necessary: requirements for children
The service is appropriate for the age & health status of the child;
the service will aid overall physical & mental growth & development; and/or
the service will assist in achieving or maintaining functional capacity.