Medical necessity is generally considered that which is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. The term clinical medical necessity is also used. Evidence-based medicine (EBM) applies the scientific method to medical practice. ... Standards of care are medical or psychological guidelines, and can be general or specific. ...

Medicare (US)

Medicare uses medical necessity as a way to determine if they should pay for goods or services. They consider medical necessity to include that which is reasonable and necessary for the diagnosis or treatment of illness, injury, or to improve the function of a malformed body member.

Medicare has a number of policies, including National Coverage Determinations (NCDs) and Local Medical Review Policy (LMRP) (also known as Local Coverage Determinations (LCDs)), which line out what is and is not covered. In a small number of cases, Medicare may even determine if a method of treating a patient should be covered on a case-by-case basis. Even if a service is accepted as reasonable and necessary, coverage may be limited if the service is provided more frequently than allowed under standard policies or standards of care.

See also

• Certificate of medical necessity (CMN)
• Advance beneficiary notice (ABN)
• Advanced Determination of Medicare Coverage (ADMC)

External Links

• Your Medicare Coverage from medicare.gov
• Medicare Coverage Database which includes NCDs, LMRP/LCDs, as well as NCAs & CALs, from cms.hhs.gov
• Physician Fee Schedule lookup at cms.hhs.gov
• What is medical necessity? by Nancy W. Miller, as found in the Physician's News Digest