Common use of Medically Necessary Services Clause in Contracts

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. for the State plan services in Addendum VI.B VIII.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 VIII.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. for the State plan services in Addendum VI.B VII.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 VII.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. for the State plan services in Addendum VI.B and C IV, Benefit Package Service Definitions, 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 IV 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: aj) The prevention, diagnosis, and treatment of a disease, condition, and/or disorder that results in health impairments and/or disability; bk) The ability to achieve age-appropriate growth and development; cl) The ability to attain, maintain, or regain functional capacity; and dm) 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. for the State plan services in Addendum VI.B and C IV.B, Benefit Package Service Definitions, 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 IV, section 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. for the State plan services in Addendum VI.B and C IV, Benefit Package Service Definitions, 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 IV 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: aj) The prevention, diagnosis, and treatment of a disease, condition, and/or disorder that results in health impairments and/or disability; bk) The ability to achieve age-appropriate growth and development; cl) The ability to attain, maintain, or regain functional capacity; and dm) 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.