Medical(ly) Necessity definition

Medical(ly) Necessity. (ary)” means, unless otherwise defined by the Payor in its Health Benefits Plan, those services determined by the Payor or its Designated Representative to be (i) preventative, diagnostic, and/or therapeutic in nature, (ii) specifically related to the condition which is being treated/evaluated, (iii) rendered in the least costly medically appropriate setting (e.g., inpatient, outpatient, office), based on the severity of illness and intensity of service required, and (iv) not primarily for the Member’s convenience or that of his or her physician.
Sample 1
Medical(ly) Necessity or "MEDICAL NECESSITY" shall mean services or supplies (including drugs) provided to a Subscriber by Agency, physician or other providers that are required to identify or treat a patient's illness or injury and which as determined by BCBST are:
Sample 1
Medical(ly) Necessity means any medical service or medical supply which is used to identify or treat an illness or injury, is appropriate to the patient's diagnosis and status of recovery, recommended to the self-insured employer or carrier in writing by an authorized treating physician, and is consistent with the location of service, the level of care provided, and the utilization review requirements consistent with this section applicable practice parameters. The service should be widely accepted among practicing health care providers, based on scientific criteria, and determined to be reasonably safe. The service must not be of an experimental, investigative, or research in nature. ,except in those instances in
Sample 1

Examples of Medical(ly) Necessity in a sentence

  • We may require that Medically Necessity be demonstrated annually.

  • The prospective determination of Medically Necessity and Appropriateness is made by the Covered Person's physician for the first 180 days of network treatment.

  • The prospective determination of Medically Necessity and Appropriateness is made by the Covered Person's Physician for the first 180 days of network treatment.

  • The prospective determination of Medically Necessity and Appropriateness is made by the Covered Person’s physician for the first 180 days of In-Network treatment.

  • Medically Necessity is defined under 907 KAR 3:130 or other applicable Kentucky Laws or Regulations and provided in accordance with 42 CFR 440:230, including children’s services pursuant to 42 U.S.C. 1396d(r).Utilization Management decision making is based only on appropriateness of care and service, existence of coverage and available criteria.

  • A significant variation in normal development in one or more of the following areas measured by appropriate diagnostic instruments and procedures and identified by the American Academy of Pediatrics as an appropriate developmental milestone based upon the Medically Necessity of the Covered Person: treatment of autism; cognitive development; physical development; communication development; social-emotional development or adaptive development.

  • All prescription drug charges are subject to review for Medically Necessity and for eligi- bility under the Prescription Benefits and Exclusions of the SHBP.

  • Treatment of Autism Spectrum Disorders when determined by a Physician or licensed psychologist that the treatment is a Medically Necessity.

  • Medically Necessity would include, but is not limited to cases of morbid obesity where weight is at least twice the ideal amount specified for frame, age, height, and gender in the most recent generally accepted life insurance tables, and where the patient has an underlying medical condition resulting from or affected by obesity.

  • The prospective determination of Medically Necessity and Appropriateness is made by the Covered Person’s Physician for the first 180 days of In-Network treatment.

Related to Medical(ly) Necessity

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

  • 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

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

  • Medically fragile means the condition of a child who requires the availability of twenty-four-hour skilled care from a health care professional or specially trained staff or volunteers in a group care setting. These conditions may be present all the time or frequently occurring. If the technology, support and services being received by the medically fragile children are interrupted or denied, the child may, without immediate health care intervention, experience death.

  • Medically Necessary Treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:

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

  • Preventive Care means certain Preventive Care services.

  • Respiratory care practitioner means a person who is

  • Behavioral health disorder means either a mental disorder

  • Adolescent means a Medicaid patient 17 years or younger.

  • Community mental health program means all mental health

  • Psychiatric hospital means an Institution constituted, licensed, and operated as set forth in the laws that apply to Hospitals, which meets all of the following requirements:

  • Behavioral health provider means a person licensed under 34 chapter 18.57, 18.57A, 18.71, 18.71A, 18.83, 18.205, 18.225, or 18.79

  • DME means durable medical equipment, which is an item or appliance that can withstand repeated use, is designed to serve a medical purpose, and is not generally useful to a person in the absence of a medical condition, illness, or injury.

  • Respiratory care means the practice of the allied health profession responsible for the direct and

  • 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 history means information regarding any:

  • Psychiatric nurse means a registered nurse who has

  • Outpatient means a person who is receiving care other than on an inpatient basis, such as: • in a provider’s office; • in an ambulatory surgical center or facility; • in an emergency room; or • in a clinic. .

  • disaster management means a continuous and integrated process of planning, organising, coordinating and implementing measures which are necessary or expedient for—

  • Iatrogenic infertility means an impairment of fertility by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.

  • Disaster Management Act means the Disaster Management Act, 2002 (Act No.57 of 2002)

  • Deaf/blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational problems that they cannot be accommodated in special education programs solely for students with deafness or students with blindness.

  • Medical home means a team approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient’s family; utilizes the partnership to access and integrate all medical and nonmedical health-related services across all elements of the health care system and the patient’s community as needed by the patient and the patient’s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the characteristics specified in section 135.158.

  • State health plan means the employee and retiree insurance program provided for in Article 5, Chapter 11, Title 1.