Medical necessities are an indication created by health insurance companies to determine “medically necessary” procedures and interventions. Payors, including private health insurers, Medicare and Medicaid, use this distinction to indicate which healthcare services they cover. Specific policies differ by insurer. For example, if a healthcare service is not “medically necessary,” the insurer may not cover all or any of it.
Notably, state law may also determine the definition of a medical necessity.
Generally, medically necessary services include those that are:
- Accepted by medical standards
- Appropriate and necessary to treat, cure, relieve or diagnose an injury, illness, disease or condition
- Provided to treat, cure, relieve or diagnose an injury, illness, disease or condition (not including clinical trial or experimental, cosmetic or investigative services)
Often, policies factor in costs, settings and alternative services, as well.