Medical Necessity Examples Clause Samples
The "Medical Necessity Examples" clause defines what constitutes a medically necessary service or treatment under the agreement. It typically provides specific scenarios or types of care that are considered medically necessary, such as hospital stays for acute illness or prescribed medications for chronic conditions. By offering concrete examples, this clause helps clarify the scope of covered services and reduces ambiguity, ensuring that both parties understand which treatments will be eligible for coverage or reimbursement.
Medical Necessity Examples. Examples of hospitalization and other Health Care Services that are not Medically Necessary include:
i. staying in the Hospital because arrangements for discharge have not been completed;
ii. staying in the Hospital because supervision in the home, or care in the home, is not available or is inconvenient; or being hospitalized for any service which could have been provided adequately in an alternate setting (e.g., Hospital outpatient department);
iii. inpatient admissions to a Hospital, Skilled Nursing Facility, or any other facility for the purpose of Custodial Care, convalescent care, or any other service primarily for the convenience of a Member, his family members or a provider; or
iv. use of laboratory, x-ray, or other diagnostic testing that has no clear indication, or is not expected to alter your treatment.