What happened to all of the links to State documents regarding Medical Necessity?
Medical Necessity
Beyond the screening and preventive health services covered under EPSDT, the Medicaid benefit for children and adolescents, diagnostic and treatment services are also covered to correct or ameliorate a child’s physical or mental condition(s). In general, states must ensure the provision of, and pay for, any services, including treatment, in accordance with mandatory and optional benefits identified in section 1905(a) of the Social Security Act, determined to be “medically necessary” for the child or adolescent. The determination of whether a service is medically necessary must be made on a case-by-case basis, taking into account the particular needs of the child.
States are permitted (but not required) to set parameters that apply to the determination of medical necessity in individual cases, but those parameters may not contradict or be more restrictive than the federal statutory requirement. In states where health care is delivered to enrolled children through managed care organizations (MCOs), the MCOs must make medical necessity determinations according to parameters set by the state, or according to the federal statutory requirements if the state has not adopted its own parameters. This section shares information on and links to individual state definitions of medical necessity for children enrolled in Medicaid.
Alabama | The Alabama Medicaid Agency uses the federal statutory definition for medical necessity. The state requires that medical necessity be documented in a beneficiary’s medical record with supporting documentation such as: Laboratory test results, diagnostic test results, history (past attempts of management if applicable), signs and symptoms, etc. All Medicaid services are subject to retrospective review for medical necessity. |
Alaska |
Alaskan relies on the federal definition through state legislation defining EPSDT covered services as follows:
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Arizona | Arizona Administrative Code defines medically necessary to mean a covered service provided by a physician or other licensed practitioner of the healing arts within the scope of practice under State law to prevent disease, disability or other adverse conditions or their progression, or prolong life. |
Arkansas |
Arkansas has adopted the Federal statutory language in defining medical necessity in its EPSDT provider manual. In addition the state requires primary care physicians (PCPs) to complete both a PCP agreement and an EPSDT agreement. The EPSDT agreement requires adherence to billing and screening standards. The PCP provider agreement also does not define medical necessity, but it requires general adherence to, “all pertinent Medicaid policies, regulations and State Plan standards.”
For services that are not included in the Arkansas Medicaid State Plan, the PCP must complete form DMS-693, titled Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Prescription/Referral for Medically Necessary Services/Items Not Specifically Included in the Medicaid State Plan.
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California |
The California Welfare and Institutions Code (Section 14059.5) states that:
“A service is ‘medically necessary’ or a ‘medical necessity’ when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.”
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Colorado |
According to regulations (10 CCR 2505-10, Section 8.076.1.8) in Colorado:
“Medical necessity means a Medical Assistance program good or service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, injury, or disability. It may also include a course of treatment that includes mere observation or no treatment at all. The good or service must be: Code of Colorado Regulations 53
The state also has an EPSDT-specific definition (10 CCR 2505-10 8.280.1):“Medical Necessity means that a covered service shall be deemed a medical necessity or medically necessary if, in a manner consistent with accepted standards of medical practice, it:
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Connecticut |
Regulations in Connecticut define medical necessity for Medicaid enrollees to mean:
“…those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual’s medical condition, including mental illness, or its effects, in order to attain or maintain the individual’s achievable health and independent functioning provided such services are:
(1) Consistent with generally-accepted standards of medical practice (….)
(2) clinically appropriate in terms of type, frequency, timing, site, extent and duration and considered effective for the individual’s illness, injury or disease; (3) not primarily for the convenience of the individual, the individual’s health care provider or other health care providers; (4) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual’s illness, injury or disease; and (5) based on an assessment of the individual and his or her medical condition.” They also establish that:
“The Commissioner of Social Services shall provide Early and Periodic Screening, Diagnostic and Treatment program services, as required and defined as of December 31, 2005, by 42 USC 1396a(a)(43), 42 USC 1396d(r) and 42 USC 1396d(a)(4)(B) and applicable federal regulations, to all persons who are under the age of twenty-one and otherwise eligible for medical assistance under this section.”
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Delaware | No information at this time. |
District of Columbia | The District’s EPSDT manual currently defines medical necessity for EPSDT services as “medical, surgical or other services required for the prevention, diagnosis, cure, or treatment of a health related illness, condition or disability including services necessary to prevent a detrimental change in either medical, behavioral, mental or dental health status.” |
Florida |
The Florida Administrative Code (Rule 59G-1.010) states:
“ ‘Medically necessary’ or ‘medical necessity’ means that the medical or allied care, goods, or services furnished or ordered must:
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Georgia |
The Georgia Code (at § 49-4-169.1) defines medically necessary services for children as “services or treatments that are prescribed by a physician or other licensed practitioner, and which, pursuant to the EPSDT Program, diagnose or correct or ameliorate defects, physical and mental illnesses, and health conditions, whether or not such services are in the state plan.”
It further specifies that “’Correct or ameliorate’ means to improve or maintain a child’s health in the best condition possible, compensate for a health problem, prevent it from worsening, prevent the development of additional health problems, or improve or maintain a child’s overall health, even if treatment or services will not cure the recipient’s overall health.”
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Hawaii | As stated in Hawaii’s administrative rules (Hawaii Administrative Rules 1700.1-41), “medical necessity” refers to those procedures and services that:“are considered to be necessary and for which payment will be made. Medically necessary health interventions (services, procedures, drugs, supplies, and equipment) must be used for a medical condition. There shall be sufficient evidence to draw conclusions about the intervention’s effects on health outcomes. The evidence shall demonstrate that the intervention can be expected to produce its intended effects on health outcomes. The intervention’s beneficial effects on health outcomes shall outweigh its expected harmful effects. The intervention shall be the most cost-effective method available to address the medical condition. Sufficient evidence is provided when evidence is sufficient to draw conclusions, if it is peer-reviewed, is well-controlled, directly or indirectly relates the intervention to health outcomes, and is reproducible both within and outside of research settings.” |
According to regulations in Idaho,
“A service is medically necessary if:
Idaho requires prior authorization for the following list of services:
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Illinois’ administrative code directs that Healthy Kids, the state’s EPSDT program, “shall pay for necessary medical care (see Section 140.2), diagnostic services, treatment or other measures medically necessary (e.g., medical equipment and supplies) to correct or ameliorate defects, and physical and mental illnesses and conditions which are discovered or determined to have increased in severity by medical, vision, hearing or dental screening services.” Section 140.2 defines of “necessary medical care” in the case of EPSDT as care that is “generally recognized as standard medical care required because of disease, disability, infirmity or impairment.”
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Indiana |
The Indiana Administrative Code (405 IAC 5-2-17) defines medically reasonable and necessary services for Medicaid.
“‘Medically reasonable and necessary service’ as used in this title means a covered service (as defined in section 6 of this rule) that is required for the care or well being of the patient and is provided in accordance with generally accepted standards of medical or professional practice. For a service to be reimbursable by the office, it must:
(1) be medically reasonable and necessary, as determined by the office, which shall, in making that determination, utilize generally accepted standards of medical or professional practice; and
(2) not be listed in this title as a noncovered service, or otherwise excluded from coverage.” |
Iowa’s Medicaid program covers medically necessary services offered by participating providers. It has a single medical necessity definition for all services. It does not have distinct definitions for children, oral health services, or behavioral health services. In Iowa, in order to be medically necessary, services must:
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Kansas |
The State of Kansas defines medical necessity as follows:
“Medical necessity means that a health intervention is an otherwise covered category of service, is not specifically excluded from coverage, and is medically necessary, according to all of the following criteria:
Kansas statutes also add that KAN Be Healthy services (see pgs. 60-61) also include:
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Kentucky | According to the Kentucky Administrative Regulations, to be medically necessary or a medical necessity, a covered benefit shall be:
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Louisiana’s definition of medical necessity, as defined in Title 50, Public Health Medical Assistance, Part I, Subpart 1, Chapter 11, §1101 is as follows:
The Medicaid director, in consultation with the Medicaid medical director, may consider authorizing services at his discretion on a case-by-case basis.
Additionally, each of the five managed care plans that contract with Bayou Health have their own policies for referrals and prior authorization for services.
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Maine’s Medicaid Benefits Manual defines “medically necessary services” as those that are:
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Under the Code of Maryland Regulations, “Medically necessary” means that the service or benefit is:
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No information at this time.
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Michigan relies on the federal medical necessity definition for EPSDT, and does not have a general state-level medical necessity definition for Medicaid services.
Michigan’s Medicaid State Plan does contain a medical necessity definition for specific Medicaid services, such as the definition used for physical therapy services and psychological, counseling and social work:
“Medically necessary services are health care, diagnostic services, treatments and other measures to correct or ameliorate any disability and/or chronic condition.”
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Minnesota’s Administrative Rules define medical necessity or medically necessary as “a health service that is consistent with the recipient’s diagnosis or condition” and:
The Administrative Rules describe EPSDT services using the federal definition. |
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Mississippi |
Mississippi’s Medicaid provider policy manual defines “medically necessary services” as those that are
In the state’s Medicaid manual for EPSDT services, a “medically necessary service” is defined as “any service that is reasonably necessary to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap or cause physical deformity or malfunction. There must also be no other equally effective, more conservative, or substantially less costly course of treatment available or suitable for the client requesting the service.”
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No information at this time. | |
Montana |
Regulations in Montana define a medical necessary service as:
“ a service or item reimbursable under the Montana Medicaid program, as provided in these rules:
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Regulations in Nebraska establish that:”Nebraska Medical Assistant Program (NMAP) applies the following definition of medical necessity: Health care services and supplies which are medically appropriate and –
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Nevada |
Nevada’s Medicaid Services Manual defines medical necessity as:
“A health care service or product that is provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to: diagnose, treat or prevent illness or disease; regain functional capacity; or reduce or ameliorate effects of an illness, injury or disability.
The determination of medical necessity is made on the basis of the individual case and takes into account:
Medical Necessity shall take into account the ability of the service to allow recipients to remain in a community based setting, when such a setting is safe, and there is no less costly, more conservative or more effective setting. “
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New Hampshire |
Regulations in New Hampshire define medically necessary as:
“health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are:
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New Jersey defaults to the federal definition of medical necessity for the EPSDT benefit. The state does not have a formal state-level medical necessity definition for Medicaid, deferring to clinical judgment and industry best practices. In discussing Medicaid-covered services, the New Jersey Administrative Code (N.J.A.C. 10:49-5.1) notes that:
“Any service limitations imposed will be consistent with the medical necessity of the patient’s condition as determined by the attending physician or other practitioner and in accordance with standards generally recognized by health professionals and promulgated through the New Jersey Medicaid program.”
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In New Mexico, medically necessary services are defined in regulation as clinical and rehabilitative physical or behavioral health services that:
The state does not have distinct definitions for children, oral health services, or behavioral health services. |
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New York state law provides a definition of medical necessity:
“Medical assistance” shall mean payment of part or all of the cost of medically necessary medical, dental and remedial care, services and supplies, as authorized in this title or the regulations of the department, which are necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for normal activity, or threaten some significant handicap and which are furnished an eligible person in accordance with this title and the regulations of the department.
The state does not have distinct statutory definitions for children, oral health services, or behavioral health services.
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North Carolina has adopted the Federal definition of medical necessity, and the state’s EPSDT Policy Instructions elaborate further and define the term “Ameliorate”:
“EPSDT services include any medical or remedial care that is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition [health problem]. This means that EPSDT covers most of the treatments a recipient under 21 years of age needs to stay as healthy as possible, and North Carolina Medicaid must provide for arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services. “Ameliorate” means to improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Even if the service will not cure the recipient’s condition, it must be covered if the service is medically necessary to improve or maintain the recipient’s overall health.”
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North Dakota |
North Dakota Administrative Code 75-02-02-03.2 states:
“‘Medically necessary’ includes only medical or remedial services or supplies required for treatment of illness, injury, diseased condition, or impairment; consistent with the patient’s diagnosis or symptoms; appropriate according to generally accepted standards of medical practice; not provided only as a convenience to the patient or provider; not investigational, experimental, or unproven; clinically appropriate in terms of scope, duration, intensity, and site; and provided at the most appropriate level of service that is safe and effective.”
North Dakota’s Medicaid Provider Manual lists Health Tracks screening services, and then notes that Health Tracks services also include:
“Other necessary health care to provide diagnosis and treatment to correct or improve defects, physical and mental illnesses and conditions discovered by the screening services.”
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Ohio |
According to regulations (Ohio Administrative Code 5160-1-01) in Ohio:
“‘Medical necessity’ is a fundamental concept underlying the medicaid program. Physicians, dentists, and limited practitioners render, authorize, or prescribe medical services within the scope of their licensure and based on their professional judgment regarding medical services needed by an individual. Unless a more specific definition regarding medical necessity for a particular category of service is included within division-level 5101:3 of the Administrative Code, ‘medically necessary services’ are defined as services that are necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. A medically necessary service must:
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No information at this time. | |
Under the Oregon Administrative Rules “Medically Appropriate” means:“(127) “Medically Appropriate” means services and medical supplies that are required for prevention, diagnosis or treatment of a health condition that encompasses physical or mental conditions, or injuries and which are:
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No information at this time. | |
No information at this time. | |
South Carolina |
Medicaid policy manuals in South Carolina define medical necessity as:
“Medical Necessity (the provision of which may be limited by specific manual provisions, bulletins, and other directives) is directed toward the maintenance, improvement, or protection of health or toward the diagnosis and treatment of illness or disability.”
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South Dakota |
South Dakota’s Medicaid program has a single medical necessity definition for all services. It does not have distinct definitions for children, oral health services, or behavioral health services. According to the state’s administrative rules, a service must meet the following criteria to be considered medically necessary:
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Tennessee |
Tennessee Code 71-5-144 defines Medical Necessity as follows:
“To be determined to be medically necessary, a medical item or service must be recommended by a physician who is treating the enrollee or other licensed healthcare provider practicing within the scope of the physician’s license who is treating the enrollee and must satisfy each of the following criteria:
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Texas |
Under the Texas Administrative Code, medically necessary means:
“For Medicaid members birth through age 20, the following Texas Health Steps services:
The definition also specifies that medical necessity for children may take into account other factors relevant in the state’s adult medical necessity definition, including the following.For non-behavioral health services, that services are:
For behavioral health services, that services:
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No information at this time. | |
No information at this time.
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Virginia |
Virginia uses the federal definition of medical necessity for EPSDT in the “What is EPSDT?” section of the Managed Care Resource Guide.
Virginia’s EPSDT program goals are to keep children as healthy as possible by:
The guide adds that “all requests for EPSDT treatment services must:
Services that are considered experimental or investigational are not covered.
EPSDT Specialized Services are medically necessary treatment services that are not a routinely covered service through Virginia Medicaid. All EPSDT “specialized services” must be a service that is allowed by the Centers for Medicare and Medicaid Services (CMS). The allowable treatment services are defined in the United States Code in 42 U.S.C. sec 1396d (r) (5).”
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Medical necessity is defined in the Washington Administrative Code (WAC 182-500-0070) as:
“a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the client requesting the service. For the purposes of this section, ‘course of treatment’ may include mere observation or, where appropriate, no medical treatment at all.”
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Medicaid provider manuals in the state define medical necessity as:“Services or supplies that are proper and needed to diagnose or treat a medical condition.” | |
Wisconsin |
Under Wisconsin’s administrative code (DHS 101.03(96m)), medical necessary services are:
“(a)Required to prevent, identify or treat a recipient’s illness, injury or disability; and
(b) Meets the following standards:
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Wyoming |
Wyoming Rules and Regulations define Medical Necessity for the Health Check program as follows:
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What happened to all of the links to State documents regarding Medical Necessity?