Medically Necessary Care Sample Clauses

Medically Necessary Care. 1. With respect to services other than mental health services: This is diagnostic testing and medical treatment and prescription drug use which is medically appropriate to your physical diagnosis for an injury or illness, and preventive services covered in this SPD. Medically necessary care must meet the following criteria: • it meets clinically accepted medical services and practice parameters of the general medical community; and • it meets the most appropriate and cost-effective level of medical services, prescription drugs or supplies that can be safely provided. When applied to inpatient care, it further means that the medical symptoms or conditions require that the medical services or supplies cannot be safely provided in a lower level of care setting; and • it restores or maintains health; or • it prevents deterioration of your condition; or • it prevents the reasonably likely onset of a health problem or detects an incipient problem. To be considered medically necessary care, it must not be maintenance or custodial care, or ineffective care, or otherwise excluded under this SPD. The fact that an authorized Network, or Non-Network, Provider prescribes treatment does not necessarily mean the treatment is covered under this Plan.