Florida Health Insurance Definitions

Florida Health Insurance Terms:
"Medically Necessary"

Define: "Medically Necessary":

Those covered services required to preserve and maintain the health status of a covered person in accordance with the accepted standards of medical practice in the medical community in the area where services are rendered. In other words, services or treatments are considered medically necessary and appropriate if they could not have been omitted without adversely affecting the patient's condition or the quality of medical care provided.

More Examples of Medically Necessary:

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; and can be safely provided. HMO clinicians may review a PCP’s proposed course of treatment to determine medical necessity.

Coverage decisions can ultimately be traced back to three words in the original health policy contract: medically necessary and investigational. Investigational as a coverage exclusion applies to the minority of cases, in which there is inadequate data to validate the effectiveness of the intervention. In contrast, the majority of coverage decisions are based on medical necessity.

Over the years the concept of medical necessity has evolved to encompass a multitude of medical management strategies. This discussion highlights the variable uses of the concept of medical necessity in terms of: (1) Determining the most appropriate intensity of service and place of service; (2) determining whether the proposed therapy is medically appropriate for the patient's condition; (3) distinguishing between medically necessary services and those that are performance enhancing or discretionary in nature; (4) making a distinction between medically necessary, cosmetic, and reconstructive services; and (5) defining medical necessity in accordance with generally accepted principles of good medical practice.

Further details - Medically Necessary: MORE FACTS


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