Medically Necessary or Medical Necessity. Services that include medical or allied care, goods or services furnished or ordered to:
Medically Necessary or Medical Necessity a. Medically Necessary or Medical Necessity means the use of any appropriate medical treatment, service, equipment or supply as provided by a Hospital, Skilled Nursing Facility, Physician or other provider which is necessary, as determined by AvMed, for the diagnosis, care or treatment of a Member's illness or injury and which is:
Medically Necessary or Medical Necessity. Covered Service(s) provided by a physician or other licensed practitioner of the healing arts within the scope of practice under State law to prevent disease, disability, or other adverse health conditions or their progression, or to prolong life and as otherwise defined with this Appendix.
Medically Necessary or Medical Necessity. As defined in K.A.R. 30-5-58 (ooo), (1) a health intervention that is otherwise a Covered Service, is not specifically excluded from coverage, and is medically necessary, according to all of the following criteria:
Medically Necessary or Medical Necessity. Medical necessity is determined by generally accepted North Carolina community practice standards as verified by independent Medicaid consultants. As required by 10A NCAC 25A.0201, a medically necessary service may not be experimental in nature.
Medically Necessary or Medical Necessity. Those health care services that are in accordance with generally accepted, evidence-based medical standards or that are considered by most physicians (or other independent licensed practitioners) within the community of their respective professional organizations to be the standard of care. In order to be considered Medically Necessary, services must be: (1) deemed reasonably necessary to diagnose, correct, cure, alleviate or prevent the worsening of a condition or conditions that endanger life, cause suffering or pain or have resulted or will result in a handicap, physical deformity or malfunction; and (2) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. Any such services must be clinically appropriate, individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and neither more nor less than what the recipient requires at that specific point in time. Services that are experimental, non-FDA approved, investigational, or cosmetic are specifically excluded from Medicaid coverage and will be deemed “not medically necessary.”
Medically Necessary or Medical Necessity. Describes those services necessary for screening and assessing the presence of a mental illness, and/or required to identify and evaluate a mental illness that is inferred or suspected; and/or intended to treat, ameliorate, diminish or stabilize the symptoms of mental illness, including impairment of functioning; and/or designed to provide rehabilitation or habilitation for the recipient to attain or maintain an adequate level of functioning. The determination of a medically necessary service must be based upon a person centered planning process. Services selected based upon medical necessity criteria should be: Delivered in a timely manner, with an immediate response to emergencies in a location accessible to the recipient. Responsive to particular needs of multi-cultural populations and furnished in a culturally relevant manner. Provided in a least restrictive appropriate setting (inpatient and residential treatment shall be used only when less restrictive levels of treatment have been unsuccessful or cannot be safely provided). Delivered consistent with national standards of practice, including standards of practice in community psychiatry, psychiatric rehabilitation and in substance abuse, as defined by standard clinical references, generally accepted professional practice or empirical professional experience. Provided in sufficient amount, duration and scope to reasonably achieve their purpose.
Medically Necessary or Medical Necessity. Health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for normal activity, or threaten some significant handicap.
Medically Necessary or Medical Necessity. In addition to Section 3.1(iii) and as required by the State Contract, Medically Necessary or Medical Necessity means ODM requirements as stated in OAC Chapter 5160.
Medically Necessary or Medical Necessity. Medically Necessary services are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A Medically Necessary service must:
