Common use of Medically Necessary Clause in Contracts

Medically Necessary. (MEDICAL NECESSITY) means that the orthodontic services provided to treat your illness or injury, upon review by BCBSRI are: • appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • not primarily for the convenience of the member, the member’s family or provider of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether the orthodontic service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section 5. We review medical necessity on a case-by-case basis. The fact that your dentist performed or prescribed a procedure or treatment does not mean that it is medically necessary. We determine medical necessity solely for purpose of claims payment under this plan.

Medically Necessary. (MEDICAL NECESSITY) means that the orthodontic services provided to treat your illness or injury, upon review by BCBSRI are: •  appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; •  appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; •  not primarily for the convenience of the member, the member’s family or provider of such member; and •  the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether the orthodontic service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section 5. We review medical necessity on a case-by-case basis. The fact that your dentist performed or prescribed a procedure or treatment does not mean that it is medically necessary. We determine medical necessity solely for purpose of claims payment under this plan.