CE Required Article #1A

Part 1: Medical Necessity in Private Health Plans

TAKE COURSE (NL1005A)
Pre-approved-10 CE hrs

While variation exists in the opinions expressed in this article, a significant level of consensus exists on three basic issues.

• The first is that merely because a recommended treatment falls within the zone of professionally accepted medical practice does not mean it must be covered.
  
• The second is that a recommended definition of medical necessity should be multidimensional and should consider factors such as cost, convenience, and relative effectiveness compared to other treatments based on various forms of evidence.
  
• Third, the authors uniformly recommend broadening the scope of when an intervention can be considered necessary (i.e., not merely to diagnose and treat an illness but also to improve functioning, avert deterioration, and maintain functioning).

For new interventions, effectiveness is determined by scientific evidence. For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, then by expert opinion; and cost-effective for this condition compared to alternative interventions, including no intervention.

The American Medical Association (AMA defines medically necessary/medical necessity as:

health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is:

 a) in accordance with generally accepted standards of medical practice;

b) clinically appropriate in terms of type, frequency, extent, site, and duration; and

c) not primarily for the convenience of the patient, physician, or other health care provide

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