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.
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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.
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Related to Medically Appropriate/Medical Necessity

  • 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.

  • Developmentally appropriate means suitable to the chronological age range and developmental characteristics of a specific group of children.

  • Primary care physician means a physician who is a family

  • Objective medical evidence means reports of examinations or treatments; medical

  • Medically Necessary Services means those covered services that are, under the terms and conditions of the contract, determined through contractor utilization management to be:

  • Community mental health program means all mental health

  • Medical cannabis dispensary means an organization issued a

  • Supervising physician means any physician licensed under Iowa Code chapter 148, 150, or 150A. The supervising physician is responsible for medical direction of emergency medical care personnel when such personnel are providing emergency medical care.

  • Medically Necessary Leave of Absence means a Leave of Absence by a full-time student Dependent at a postsecondary educational institution that:

  • Respiratory care practitioner means a person who is

  • Medical physicist means a person trained in evaluating the performance of mammography equipment and facility quality assurance programs and who meets the qualifications for a medical physicist set forth in 41.6(3)“c.”

  • Medical cannabis means the same as that term is defined in Section 26-61a-102.

  • Health practitioner means a registered health practitioner registered or licensed as a health practitioner under an appropriate law of the State of Tasmania.

  • medical authority means the medical authority as referred to in clause (p) of section 2 of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 or such other medical authority as may, by notification, be specified by the Central Government for certifying “autism”, “cerebral palsy”, “multiple disabilities”, “person with disability” and “severe disability” referred to in clauses (a), (c), (h), (j) and (o) of section 2 of the National Trust for Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities Act, 1999;

  • Licensed mental health professional or "LMHP" means a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, certified psychiatric clinical nurse specialist, licensed behavior analyst, or licensed psychiatric/mental health nurse practitioner.

  • Authorized medical physicist means an individual who:

  • Qualified mental health professional means a licensed medical practitioner or any other person meeting the qualifications specified in OAR 309-019-0125.

  • Practice of medicine or osteopathic medicine means the prevention, diagnosis and treatment of

  • Medical examination means the preliminary assessment of a person by an authorized health worker or by a person under the direct supervision of the competent authority, to determine the person’s health status and potential public health risk to others, and may include the scrutiny of health documents, and a physical examination when justified by the circumstances of the individual case;

  • Psychiatric nurse means a registered nurse who has

  • Medical evaluation means the process of assessing an individual's health status that includes a medical history and a physical examination of an individual conducted by a licensed medical practitioner operating within the scope of his license.

  • Emergency medical technician means a person who is either an EMT-I, EMT-II, or EMT-P (paramedic), and possesses a valid certificate or license in accordance with the standards of Division 2.5 (commencing with Section 1797) of the Health and Safety Code.

  • Licensed health care practitioner means a physician, as defined in Section 1861(r)(1) of the Social Security Act, a registered professional nurse, licensed social worker or other individual who meets requirements prescribed by the Secretary of the Treasury.