Common use of Medically Necessary Services Clause in Contracts

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. Medically necessary services are defined as services, supplies, or equipment provided by a licensed health care professional that: a. Are are appropriate and consistent with the diagnosis or treatment of the patient's condition, illness, or injury; b. Are are in accordance with the standards of good medical practice consistent with the individual patient's condition(s); c. Are are not primarily for the personal comfort or convenience of the Enrollee, family, or Provider; d. Are are the most appropriate services, supplies, equipment, or levels of care that can be safely and efficiently provided to the Enrollee; e. Are 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 are not experimental or investigational or for research or education; g. Are are provided by an appropriately licensed practitioner; and h. Are 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.