Medically Necessary Services Clause Samples
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Medically Necessary Services for the State plan services in Addendum VI.B and C medically necessary has the meaning in Wis. Admin. Code DHS §101.03(96m): Medicaid services (as defined under Wis. Stat. § 49.46 and Wis. Admin. Code § DHS 107) that are required to prevent, identify or treat a member’s illness, injury or disability; and that meet the following standards:
a) Are consistent with the member’s symptoms or with prevention, diagnoses or treatment of the member’s illness, injury or disability;
b) Are provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;
c) Are appropriate with regard to generally accepted standards of medical practice;
d) Are not medically contraindicated with regard to the member’s diagnoses, symptoms, or other medically necessary services being provided to the member;
e) Are of proven medical value or usefulness and, consistent with Wis. Admin. Code § DHS 107.035 are not experimental in nature;
f) Are not duplicative with respect to other services being provided to the member;
g) Are not solely for the convenience of the member, the member’s family or a provider;
h) With respect to prior authorization of a service and other prospective coverage determinations made by DHS, are cost-effective compared to an alternative medically necessary service which is reasonably accessible to the member; and
i) Is the most appropriate supply or level of service that can safely and effectively be provided to the member. For the home and community-based waiver services in Addendum VI.A medically necessary means that the service is reasonable, appropriate and cost-effectively addresses a member’s assessed long-term care need or outcome related to any of the following purposes:
a) The prevention, diagnosis, and treatment of a disease, condition, and/or disorder that results in health impairments and/or disability;
b) The ability to achieve age-appropriate growth and development;
c) The ability to attain, maintain, or regain functional capacity; and
d) The opportunity to have access to the benefits of community living, to achieve person-centered goals, and live and work in the setting of their choice.
Medically Necessary Services. Services must be provided in a way that provides all protections to the Enrollee provided by Medicare and Medi-Cal. Per Medicare, services must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, or otherwise medically necessary under 42 U.S.C. § 1395y. In accordance with Title XIX law and related regulations, and per Medi-Cal, medical necessity means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness, or injury under the Welfare and Institutions Code section 14059.5.
Medically Necessary Services for the State plan services in Addendum VIII. B medically necessary has the meaning in Wis. Admin. Code DHS §101.03(96m): services (as defined under Wis. Stat. § 49.46
Medically Necessary Services. Services must be provided in a way that provides all protections to covered individuals provided by Medicare and Michigan Medicaid. Per Medicare, services must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, or otherwise medically necessary under 42 U.S.C. 1395y. Per Medicaid, determination that a specific service is medically (clinically) appropriate, necessary to meet needs, consistent with the person’s diagnosis, symptomatology and functional impairments, is the most cost-effective option in the most integrated setting, and is consistent with clinical standards of care. Medical necessity includes, but is not limited to, those supports and services designed to assist the person to attain or maintain a sufficient level of functioning to enable the person to live in his or her community.
Medically Necessary Services. Medically necessary services are defined as services, supplies, or equipment provided by a licensed health care professional that:
a. Are appropriate and consistent with the diagnosis or treatment of the patient's condition, illness, or injury;
b. Are in accordance with the standards of good medical practice consistent with the individual patient's condition(s);
c. Are not primarily for the personal comfort or convenience of the Enrollee, family, or Provider;
d. Are the most appropriate services, supplies, equipment, or levels of care that can be safely and efficiently provided to the Enrollee;
e. Are furnished in a setting appropriate to the patient's medical need and condition and, when applied to the care of an inpatient, further mean that the Enrollee’s medical symptoms or conditions require that the services cannot be safely provided to the Enrollee as an outpatient;
f. Are not experimental or investigational or for research or education;
g. Are provided by an appropriately licensed practitioner; and
h. Are documented in the patient's record in a reasonable manner, including the relationship of the diagnosis to the service. The only limitation on services for children is that they are necessary to correct or ameliorate defects and physical and mental illnesses and conditions discovered during an EPSDT screen, periodic or interperiodic, whether or not such services are covered or exceed the benefit limits in the Medicaid State Plan. All services determined to be medically necessary must be covered.
Medically Necessary Services. Per Medicare, services must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, or otherwise Medically Necessary under 42 U.S.C. § 1395y. In accordance with Medicaid law and regulations, and per Rhode Island Medicaid, the term “Medical Necessity,” “Medically Necessary,” or “Medically Necessary Service” means medical, surgical, or other services required for the prevention, diagnosis, cure, or treatment of a health- related condition including such services necessary to prevent a detrimental change in either medical or mental health status. Medically Necessary Services must be provided in the most cost effective and appropriate setting and shall not be provided solely for the convenience of the Enrollee or service provider.
Medically Necessary Services. As defined by the Social Security Act, Section 1905 (42 USC 1396d(a)), the State Plan, and Administrative Code, Medically Necessary Services are also the most appropriate services that help achieve age-appropriate growth and development and will allow a Member to attain, maintain, or regain capacity. Medically Necessary Services may also be those services for Members that are necessary to correct or ameliorate disorders and physical and behavioral/mental illnesses and conditions, whether such services are covered or exceed the benefit limits in the Medicaid State Plan and Title 23 of Mississippi Administrative Code.
Medically Necessary Services. Medicaid services (as defined under s. 49.46, Wis. Stats., and ch. 107 Wis. Admin. Code) that are required to prevent, identify or treat a member’s illness, injury or disability; and that meet the following standards:
a) Are consistent with the member’s symptoms or with prevention, diagnoses or treatment of the member’s illness, injury or disability;
b) Are provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;
c) Are appropriate with regard to generally accepted standards of medical practice;
d) Are not medically contraindicated with regard to the member’s diagnoses, symptoms, or other medically necessary services being provided to the member;
e) Are of proven medical value or usefulness and, consistent with ch. DHS 107.035 Wis. Admin. Code, are not experimental in nature;
f) Are not duplicative with respect to other services being provided to the member;
g) Are not solely for the convenience of the member, the member’s family or a provider;
h) With respect to prior authorization of a service and other prospective coverage determinations made by DHS, are cost-effective compared to an alternative medically necessary service which is reasonably accessible to the member; and,
i) Are the most appropriate supply or level of service that can safely and effectively be provided to the member.
Medically Necessary Services. The Subscriber acknowledges and agrees that enrollment in this program does not entitle the Subscriber to use the Fire District ambulance services or transportation that is not medically necessary. Medically necessary is defined as specific need for ambulance services or transportation where use of other services or forms of transportation, such as a private car or taxi, would be medically inappropriate. The absence of alternative services or methods of transportation does not, by itself, constitute medical necessity. If a subscriber and/or eligible dependent requests the Fire District’s ambulance service and it is determined by the Fire District that it was not medically necessary, the Subscriber/dependent will be liable for the actual costs incurred in providing such service. The Fire District reserves the right to require a physician’s certification of medical necessity.
Medically Necessary Services. Coverage hereunder excludes charges for any service or supply which is not Medically Necessary for the care of the patient's sickness, injury or condition.