Definition of Medical Necessity
A physician or clinical provider of care may have a completely different understanding, interpretation, and definition of medical necessity than the patient or a third-party insurance payer.
Medical necessity documentation from a physician or provider should include the following:
• Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is our diagnosis driver, and multiple diagnoses may be involved.
• Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. This is the medical risk vs. gain.
• The facility must have what the provider or clinician needs to render care.
Examples of what some third-party payers may be including in their medically necessary wording:
• Treatment is consistent with the symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care.
• Treatment is necessary and consistent with generally accepted professional medical standards, It must not experimental or investigational as defined by the payer.
• Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier.
• Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time.
• The disbursement of medical care and/or treatment must not be related to the patient’s or the third-party payer’s benefit.