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What is medically necessary?


*We consider covered services or supplies recommended by a treating physician or other covered provider in identifying or treating a member’s condition, disease, illness or accidental injury to be medically necessary when the service or supply is:

  1. The most appropriate supply or level of service, considering potential benefits and harms to the member.
  2. Proven to be effective in improving health outcomes;
    1. For new treatments, we determine effectiveness through scientific evidence;
    2. For existing treatments, we determine effectiveness first by scientific evidence, then by professional standards and then by expert opinion.
  3. Not primarily for the convenience of the member or covered provider.
  4. Cost-effective for this condition, compared to alternative treatments, including no treatment. Cost-effectiveness does not necessarily mean lowest price.

When applied to inpatient care, medical necessity also includes treating medical symptoms or conditions that cannot be safely and effectively treated in an outpatient setting.

A service or supply is not automatically considered medically necessary under this policy just because it is prescribed, ordered, recommended, or approved by a covered provider.

*This information is intended to provide information and does not contain all of your benefits, exclusions, limitations or non-covered services. For additional information, please refer to your policy and outline of coverage for a complete list of benefits, exclusions and limitations that apply to your coverage.