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What is medically necessary?
The term “medically necessary” refers to any type of medical service that is required to prevent or treat symptoms that would be debilitating without intervention. The various government agencies, health care organizations and insurance providers have their own definition of what is deemed medically necessary.
Whether a service is considered medically necessary often determines if it will be covered under private health insurance and through government-funded providers such as Medicare and Medicaid.
This determination is made based on accepted standard practices and on evidence-based clinical standards. In other words, health care providers use a combination of research and clinical experience to decide what treatments, diagnostic procedures and other medical services are necessary to restore or maintain a patient’s quality of life.
In addition, something that is medically necessary usually must be considered the only option or the safest or most conservative option for treatment. It also must be the most effective or most affordable option for that particular patient.
Medically necessary typically refers to serious conditions for which not treating the condition could risk someone’s life or cause a significant impairment such as a deformity or handicap.
Every provider has its own definition of medically necessary, and there is no federal definition or standard for the term. For something like Medicaid services, this means that each state has its own rules, regarding what is covered. The opinion of the patient’s physician plays a big role in determining if something is covered as medically necessary.
Learn more about what medically necessary is.
Medically necessary example
A wide range of treatments and services potentially can be considered medically necessary, but they also could be considered necessary for one patient while not for someone else.
For example, weight loss surgery could be considered medically necessary if a patient is so overweight that he or she might become debilitated because of weight, or if the person’s weight could contribute to other issues that could put that person’s life or overall health at risk.
This means that weight loss surgery could be considered medically necessary and thus covered by private insurance or by Medicaid.
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