Definition of Medical Necessity

All benefits are subject to the Plan’s definitions, limitations, and exclusions and are payable only when the criteria for medical necessity are met, as determined by the Plan Administrator or its delegate. Medical necessity means health care services that a physician, hospital, or other licensed professional or facility provider, 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:

  • In accordance with generally accepted standards of medical practice in the United States;
  • Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms;
  • 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 for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms;
  • In the case of inpatient care, not considered safe to provide on an outpatient basis;
  • Not custodial care
  • Not for cosmetic purposes; and
  • Not Experimental or Investigational (except for routine patient costs furnished in connection with certain clinical trials, as identified under “Clinical Trials” in the “Eligible Expenses” section or as otherwise specifically identified in this Plan).

For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and other relevant factors.

For medically necessary services, the Plan may compare the cost-effectiveness of alternative services or supplies when determining which of the services or supplies will be covered and in what setting medically necessary services are eligible for coverage.

The Plan may require and review a treatment plan, including the patient's history of adherence to treatment plans for the same or similar conditions, to determine medical necessity for current or future care. The patient's failure to complete a prescribed course of treatment, or leaving a health care facility against medical advice or against therapist's advice, may result in denial of benefits for the current episode of care or similar care in the future.

The fact that a physician, hospital, or other professional or facility provider has prescribed, recommended, or approved a service or supply does not, in itself, make it medically necessary or covered under this Plan.

The terms of the Plan govern the extent to which expenses are eligible for reimbursement. You and your doctor are responsible for decisions about how to treat your medical condition. You may elect not to pursue reimbursement from the Plan. However, if you wish to submit claims to the Plan, you and your doctor should be aware of:

Regardless of the amount of reimbursement (if any) that will be provided under the Medical Plan, you and your doctor are encouraged to choose the most appropriate and cost-effective treatment options.

The consultation of multiple providers for the purpose of obtaining a desired treatment, service, opinion, or diagnosis or for obtaining duplicative treatment or services may be considered by the Plan Administrator or its delegate as evidence that a treatment or service is not medically necessary. In addition, the submission of claims resulting from such activity may be considered by the Plan Administrator or its delegate to constitute fraud, waste, or abuse.

If your provider requests preauthorization for a diagnostic test, imaging, or procedure, and that request is denied because it is determined that the service does not satisfy the medical necessity requirements, the Plan will not cover the service. Except as required under applicable law, the service will be ineligible for coverage even if it is subsequently performed in an urgent care center or hospital emergency room if:

  • The service is performed for the same purpose for which the preauthorization request had been denied, and
  • No additional clinical information is presented that satisfies the medical necessity requirements.