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  • Medical Necessity in Private Health Plans
















  • Medical Necessity in Private Health Plans


    Table 3. Medical Necessity Definitions Identified in Case Law (Sorted by Case Name)

    Year Case Medical Necessity Definition1
    1996 Bancroft v. Tecumseh Products Company Covered charges include only those incurred for services or items specifically recommended by a licensed physician as necessary for the diagnosis, care, or treatment of a physical or mental condition, and falling within the Plan guidelines. For a service to be determined as necessary for medical care, it must be widely accepted by medical professionals in the United States as effective, appropriate, and essential under recognized health care standards.
    1996 Bedrick v. Travelers Insurance The Travelers determines, in its discretion, if a service or supply is medically necessary for the diagnosis and treatment of an accidental injury or sickness. This determination is based on and consistent with standards approved by Travelers medical personnel. These standards are developed, in part, with consideration to whether the service or supply meets the following: *It is appropriate and required for the diagnosis or treatment of the accidental injury or sickness. *It is safe and effective according to accepted clinical evidence reported by generally recognized medical professionals and publications. *There is not a less intensive or more appropriate diagnostic or treatment alternative that could have been used in lieu of the service or supply given. A determination that a service or supply is not medically necessary may apply to the entire service or supply or to any part of the service or supply.
    1994 Blue Cross and Blue Shield of Virginia v. Katharine Keller A medically necessary service is one required to identify or treat an illness, injury, or pregnancy-related condition which a Provider has diagnosed or reasonably suspects. To be medically necessary, the service must: be consistent with the diagnosis of your condition; be in accordance with the standards of good medical practice; not be for the convenience of the patient, the patient's family, or the Provider; and be performed in the least costly setting required by your medical condition.
    1993 Dettmer Clinic v. Associated Insurance Companies, Inc. The group contract defines "medically necessary" or "medical necessity" as those: services or supplies, provided by a Provider, Facility, or Provider Individual, which are required for treatment of illness, injury, diseased condition, or impairment and are: (a) consistent with the Insured's diagnosis or symptoms; (b) appropriate treatment according to generally accepted standards of medical practice; (c) not provided only as a convenience to the Insured or Provider (d) not Investigational or unproven; and (e) not excessive in scope, duration, or intensity to provide safe, adequate, and appropriate treatment to the Insured. Any service or supply provided at a Provider Facility will not be considered medically necessary if the Insured's symptoms or condition indicate that it would be safe to provide the service or supply in a less comprehensive setting. The fact that any particular Provider Individual may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such treatment medically necessary or make the charge a Covered Charge under this Contract.
    1996 Esdale v. American Community Mutual Insurance Company Medically necessary means recommended by a licensed physician and commonly recognized in the licensed physician's profession as proper care or treatment. Medically Necessary does not mean a procedure that is deemed experimental or investigational in nature by any appropriate technological assessment body established by any state or federal government.
    1993 Evans v. Blue Cross Blue Shield of South Carolina Medically Necessary: benefits are payable for services or supplies that are medically necessary. The simple fact that a physician has performed or prescribed something does not mean that it is medically necessary. Some services or supplies that you get may not be covered under your insurance health policy. Expenses for the following will not be paid:
    • Surgery just to make you look better (usually called cosmetic surgery)
    • Experimental surgery or services, such as acupuncture or sex change
    • Services or supplies that are not medically necessary, including luxury or convenience items and travel expenses (except those provided for human organ transplants).
    1992 Farley v. Benefit Trust Life Insurance Company The insurance contract defines "medically necessary" treatment as "drugs, therapies, or other treatments that are required and appropriate care for the sickness or the injury; and that are given in accordance with generally accepted principles of medical practice in the U.S. at the time furnished; and that are approved for reimbursement by the Health Care Financing Administration; and that are not experimental, educational, or investigational; and that are not furnished in connection with medical or other research."
    1994 Fenio v. Mutual of Omaha Insurance Company "Medically Necessary" service or supply means one which: (a) is appropriate and consistent with the diagnosis in accord with accepted standards of community practice; (b) is not considered experimental or investigative; (c) could not have been omitted without adversely affecting the insured person's condition or quality of medical care.
    1993 Florence Nightingale Nursing Service, Inc. v. Blue Cross Blue Shield of Alabama Medically Necessary means the use of a Hospital or the furnishing of other services or supplies which are necessary to treat a Member's illness or injury. To be medically necessary, the services and supplies furnished must (as determined by the Claims Administrator): be appropriate and necessary for the symptoms, diagnosis, or treatment of the Member's condition, disease, ailment, or injury; be provided for the diagnosis or direct care of the Member's medical condition; be in accordance with standards of good medical practice accepted by the organized medical community; and not be solely for the convenience of the Member, his family, his Physician or another provider of services; not be experimental or investigative; and be performed in the least costly setting the Member's medical condition requires.
    1995 Grethe v. Trustmark Insurance Company The term "Medically Necessary" as used above means: drugs, therapies, or other treatments that are required and appropriate for care of the sickness or the injury; and that are given in accordance with generally accepted principles of medical practice in the U.S. at the time furnished; and that are reimbursed by Medicare; and are not deemed to be experimental, educational, or investigational in nature by any appropriate technological assessment body established by any state or federal government; and that are not furnished in connection with medical or other research.
    1996 Harrison v. Aetna Life Insurance Company "Necessary" means a service or supply which is necessary for the: diagnosis; or care; or treatment; of the physical or mental condition involved. It must be widely accepted professionally in the United States as: effective; and appropriate; and essential; based upon recognized standards of the health care specialty involved.
    2001 Hundley v. Wenzel Medically necessary means that a service or supply is necessary and appropriate for the diagnosis and treatment of an illness or injury based on generally accepted current medical practice. A service or supply will not be considered medically necessary if any of the following apply: (1) It is provided only as a convenience to the covered person or provider; (2) It is not appropriate treatment for the covered person's diagnosis or symptoms; (3) It exceeds (in scope, duration, or intensity) the level of care that is needed to provide safe, adequate, and appropriate diagnosis or treatment; (4) It is part of an experimental treatment. The fact that any particular doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply medically necessary.
    2000 Juliano v. HMO of New Jersey, Inc., dba U.S. HealthCare The Contract defines "Medically Necessary or Medical Necessity" as appropriate and necessary services as defined by HMO which are rendered to a Member for a condition requiring, according to generally accepted principles of good medical practice, the diagnosis or direct care and treatment of an illness or injury and which are not provided only as a convenience.
    1998 Killian vs. HealthSource Provident Administrators, Inc. Medically Necessary and/or Medical Necessity-Services or supplies provided by a: (1) Hospital, (2) Physician, or (3) other qualified provider...are medically necessary if they are: (1) required for the diagnosis and/or treatment of the particular condition, disease, injury or illness; (2) consistent with the symptom or diagnosis and treatment of the condition, disease, injury, or illness; (3) commonly and usually noted throughout the medical field as proper to treat the diagnosed condition, disease, injury, or illness; and (4) the most fitting supply or level of service which can be safely given.
    1995 Kornman v. Blue Cross Blue Shield of Louisiana 1985 policy defines "medically necessary" as health services which: are appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Louisiana, could not have been omitted without adversely and severely affecting the patient's condition; are not primarily custodial care; are appropriate and can be safely used under the circumstances. Inpatient hospital services should be used only when a lesser equipped facility (e.g., outpatient hospital services, physician's office, etc) could adversely and severely affect the patient's condition. 1987 policy: "Medically Necessary" means a service or treatment which, in the judgment of the plan: (1) Is appropriate and consistent with the diagnosis and which, in accordance with accepted medical standards in the State of Louisiana, could not have been omitted without adversely affecting the patient's condition or the quality of medical care rendered; (2) Is not primarily custodial care; and (3) as to institutional care, could not have been provided in a physician's office, in the outpatient department of a hospital, or in a lesser facility without affecting the patient's condition or quality of medical care rendered.
    1998 McGraw v. Prudential Insurance To be considered "needed", a service or supply must be determined by Prudential to meet all of these tests: (a) It is ordered by a Doctor; (b) It is recognized throughout the Doctor's profession as safe and effective, is required for the diagnosis or treatment of the particular sickness or injury, and is employed appropriately in a manner and setting consistent with generally accepted United States medical standards; (c) It is neither educational nor experimental or investigational in nature. The case also mentions: "As we read the record, Prudential has modified its definition of "medical necessary" with the additional requirement the treatment provide a measurable and substantial increase in functional ability for a condition having potential for significant improvement."
    2001 Milone v. Exclusive Health Care, Inc. The Plan defines medical necessity as follows: A medically necessary service or supply means one which is ordered or authorized by the Primary Care Physician, and which the Primary Care Physician, our medical staff or our Medical Director and/or a qualified party or entity selected by us determines is: (a) provided for the diagnosis or direct treatment of an injury or sickness; (b) appropriate and consistent with the symptoms and findings or diagnosis and treatment of the member's injury or sickness; (c) provided in accord with generally accepted medical practice on a national basis; and (d) the most appropriate supply or level of service which can be provided on a cost-effective basis (including, but not limited to, inpatient vs. outpatient care, electric vs. manual wheelchair, surgical vs. medical or other types of care). The fact that the member's physician prescribes services or supplies does not automatically mean such services or supplies are medically necessary and covered by the Contract.
    1999 Milone v. Exclusive Healthcare, Inc. A medically necessary service or supply means one which is ordered or authorized by the Primary Care Physician, and with the Primary Care Physician, our medical staff or our Medical Director and/or a qualified party or entity selected by us determines is: (1) provided for the diagnosis or direct treatment of an injury or sickness; (2) appropriate and consistent with the symptoms and findings or diagnosis and treatment of the member's injury or sickness; (3) provided in accord with generally accepted medical practice on a national basis; and (4) the most appropriate supply or level of service which can be provided on a cost-effective basis (including, but not limited to, inpatient vs. outpatient care, electric vs. manual wheelchair, surgical vs. medical or other types of care). The fact that the member's physician prescribes services or supplies does not automatically mean such services or supplies are medically necessary and covered by the Contract.
    1997 Nichols v. Trustmark Insurance Company Benefits will be paid only for "medically necessary" care and treatment of sickness and injury. As used above, 'medically necessary' means: drugs, therapies, or other treatments that are required and appropriate for care of the sickness or the injury; and that are given in accordance with generally accepted principles of medical practice in the U.S. at the time furnished; and that are approved for reimbursement by the Health Care Financing Administration; and that are not experimental, educational, or investigational; and that are not furnished in connection with medical or other research.
    1994 Northwest Laundry and Dry Cleaners Health and Welfare Trust Fund v. Burzynski To be "medically necessary" under the Plan, a treatment must meet two requirements, measured under Oregon law. First, the treatment must be "appropriate and consistent with the diagnosis (in accord with accepted standards of community practice)." Second, "medically necessary" treatments "could not be omitted without adversely affecting the covered person's condition or the quality of medical care."
    2002 Rush Prudential HMO, Inc., Petitioner v. Debra C. Moran et al. A service is covered as "medically necessary" if Rush finds: (a) ?[The service] is furnished or authorized by a Participating Doctor for the diagnosis or the treatment of a Sickness or Injury or for the maintenance of a person's good health. (b) ?The prevailing opinion within the appropriate specialty of the United States medical profession is that [the service] is safe and effective for its intended use, and that its omission would adversely affect the person's medical condition. (c) ?It is furnished by a provider with appropriate training, experience, staff and facilities to furnish that particular service or supply.
    1993 Scalamandre v. Oxford Health Plans, Inc. Medically necessary services and/or supplies are defined as: the use of services or supplies as provided by a hospital, skilled nursing facility, physician, or other provider required to identify or treat a Member's illness or injury and which, as determined by the Medical Director, are: (1) Consistent with the symptoms or diagnosis and treatment of the Covered Person's condition, disease, ailment or injury; (2) Appropriate with regard to standards of good medical practice; (3) Not solely for the convenience of the Covered Person, his or her physician, hospital, or other health care provider; and (4) The most appropriate supply or level of service which can be safely provided to the Covered Person. When specifically applied to an inpatient, it further means that the Covered Person's medical symptoms or condition requires that the diagnosis or treatment cannot be safely provided to the Covered Person as an outpatient.
    2001 Smith v. Newport News Shipbuilding Health Plan The Plan defines 'necessary' as follows: A service or supply is necessary if it is for the diagnosis, care, or treatment of a physical or mental condition and widely accepted professionally in the U.S. as effective, appropriate, and essential, based upon recognized standards of the health care specialty involved.
    1997 Sophie v. Lincoln National Life Insurance Company Medically necessary is defined as: The extent of services required to diagnose or treat a Bodily Injury or Sickness which is known to be safe and effective by most Qualified Practitioners who are licensed to diagnose or treat that Bodily Injury or Sickness. Such services must be performed in the least costly setting required by the patient's condition, and must not be provided primarily for the convenience of the patient of the Qualified Practitioner.
    1997 Squillace v. Wyoming State Employee and Officials Group Insurance Board of Administration "Medically Necessary" means any services and supplies provided for the diagnosis and treatment of a specific illness, injury, or condition. Such services and supplies must be: ordered by a doctor; required for the treatment or management of a medical symptom or condition; the most efficient and economical service which can safely be provided to such person; and provided in accordance with approved and generally accepted medical or surgical practice. We may require proof in writing satisfactorily to us that any type of treatment, service, or suppy received is medically necessary. Medical necessity will be determined solely by us. The fact that a doctor may prescribe, order, recommend, or approve a service does not, in itself, make such service or supply medically necessary.
    1996 Sven v. Principal Mutual Life Insurance Company "Medically Necessary Care" is defined as: any confinement, treatment, or service that is prescribed by a physician and determined by the Company [Principal] to be: (a) necessary and appropriate; and (b) non-experimental and non-investigational and not in conflict with accepted medical standards.
    1994 Whitehead v. Federal Express Corporation Eligible expenses for treatment of an illness or injury must be medically necessary under all plan options. Medical necessity is determined by the claims paying administrator. Care that is medically necessary may include, but is not limited to, care that is: *commonly and customarily recognized as standards of good practice; *appropriate and consistent with the diagnosis or treatment of an illness or injury; *appropriate supply or level of service that can be safely provided.
    1998 Winnega v. North Central Health Protection Plan Medically necessary services or supplies are defined as: (a) Required for diagnosis or treatment of the illness or symptoms; (b) provided for the diagnosis or direct care and treatment of the illness; (c) Within the standards of normal medical practice; (d) Not primarily for the convenience of the Participant or any provider; and (e) a supply or level of services required to provide safe and adequate care.

    This information came from an FDA online article.

    *** Any medical or legal information can be incorrect or outdated - Consult a qualified source for current info ***

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