Medical necessity

Medical necessity is a term used in the United States healthcare system to describe a healthcare service that is regarded as necessary to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or aggravate a handicap, or result in illness or infirmity.

Definition

The definition of medical necessity varies from one insurance company to another. Most definitions include language to the effect that to be considered medically necessary, a service must be: reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member; and not primarily for the convenience of the patient or physician.

Determination

The determination of medical necessity is made by the patient's health care provider based on the clinical facts of the case and the provider's professional judgment. The provider's determination is then reviewed by the insurance company, which may agree or disagree with the provider's decision.

Controversies

There are many controversies surrounding the concept of medical necessity. Some of these controversies include: the lack of a standard definition of medical necessity; the subjective nature of the determination of medical necessity; and the potential for abuse by providers and insurance companies.

See also

• Health care in the United States
• Health insurance in the United States
• Healthcare reform in the United States