Medically Necessary or Medical Necessity

Healthcare services or supplies that meet accepted standards of medicine and are needed to diagnose and/or treat an illness, injury, or condition (chronic and acute) and associated symptoms.

(1) according to applicable law and/or regulations, are required to be provided to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms; or in absence of such definition,

(2) a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

(a) in accordance with Generally Accepted Standards of Medical Practice;

(b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and

(c) not primarily for the convenience of the patient, physician or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease.