Medical Necessity Standards
Services that include medical or allied care, goods or services furnished or ordered to:
1. Must be provided under the following conditions:
• Be necessary to protect life, to prevent significant illness or significant disability or to alleviate severe pain;
• Be individualized, specific and consistent with symptoms or confirm diagnosis of the illness or injury under
treatment and not in excess of the patient’s needs;
• Be consistent with the generally accepted professional Medical standards as determined by the Medicaid program, and not be experimental or investigational;
• Be reflective of the level of service that can be furnished safely and for which no equally effective and more conservative or less costly treatment is available statewide; and,
• Be furnished in a manner not primarily intended for the convenience of the member, the member’s caretaker or the provider.
2. Medically necessary or medical necessity for those services furnished in a hospital on an inpatient basis cannot, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.
3. The fact that a provider has prescribed, recommended or approved medical or allied goods or services does not, in and of itself, make such care, goods or services medically necessary, a medical necessity or a covered service/benefit.
