Medically Appropriate/Medical Necessity definition

Medically Appropriate/Medical Necessity. With respect to programs other than Medicare, Medicare Advantage and Medicaid, the term “Medically Appropriate” means or describes a vision care service(s) or treatment(s) that a PROVIDER hereunder, exercising PROVIDER’s prudent, clinical judgment would provide to a Member for the purpose of evaluating, diagnosing or treating an illness, injury, disease, or its symptoms and that is in accordance with the “Generally Accepted Standards of Medical Practice”; and is clinically appropriate in terms of type, frequency, extent site and duration; and is considered effective for the Member’s illness, injury or disease; and is not primarily for anyone’s convenience; and is not more costly than an alternative service or sequence of services that are at least as likely to produce equivalent therapeutic and/or diagnostic results as to the Member’s illness, injury, or disease.
View Source
Medically Appropriate/Medical Necessity means, services or treatments which one or more Participating Provider(s), in accordance with accepted professional practices and standards prevailing at the time of treatment and adopted by DAVIS, have determined (a) a Member requires and which are not primarily for the convenience of the Member or of the PROVIDER; (b) are appropriate to the illness or injury for which the service or treatment is performed and are appropriate to the expected outcome; (c) provide unique, essential and appropriate information when used for diagnostic purposes; (d) are appropriate to the intensity of service and level of setting; and (e) are the lowest cost alternative that effectively address and treat the medical problem.
View Source

Related to Medically Appropriate/Medical Necessity

  • Medically Appropriate means services and medical supplies required for prevention, diagnosis, or treatment of a physical or behavioral health condition or injuries that are:

  • Medical necessity means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:

  • Medically necessary care means care that is (1) appropriate and consistent with and essential for the prevention, diagnosis, or treatment of a Patient’s condition; (2) the most appropriate supply or level of service for the Patient’s condition that can be provided safely; (3) not provided primarily

  • medically approved means certified by a medical practitioner;

  • Medically Necessary means a service which is appropriate and consistent with the treatment of the condition in accordance with accepted standards of community practice.