MEDICALLY NECESSITY definition

MEDICALLY 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
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MEDICALLY 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:
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MEDICALLY 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.
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Related to MEDICALLY 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.