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:
  • The department will pay for a service recommended as a result of the EPSDT screening, if that services is an authorized service under 42 U.S.C. 1396-1396w-1.
  • The department will pay for the following additional services for children under 21 years of age if the screening identifies a need for that service:
    • podiatry services under 7 AAC 110.500 – 7 AAC 110.505;
    • nutrition services under 7 AAC 110.275;
    • private-duty nursing services under 7 AAC 110.520 – 7 AAC 110.535;
    • hospice care under 7 AAC 140.280.
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.
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.”
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
  1. Provided in accordance with generally accepted standards of medical practice in the United States;
  2. Clinically appropriate in terms of type, frequency, extent, site, and duration;
  3. Not primarily for the economic benefit of the provider or for the convenience of the client, caretaker, or provider; and
  4. Performed in a cost effective and most appropriate setting required by the client’s condition.”
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:
  1. Is found to be an equally effective treatment among other less conservative or more costly treatment options, and
  2. Meets at least one of the following criteria:
    • The service will, or is reasonably expected to prevent or diagnose the onset of an illness, condition, primary disability, or secondary disability
    • The service will, or is reasonably expected to cure, correct, reduce or ameliorate the physical, mental cognitive or developmental effects of an illness, injury or disability
    • The service will, or is reasonably expected to reduce or ameliorate the pain or suffering caused by an illness, injury or disability.
    • The service will, or is reasonably expected to assist the individual to achieve or maintain maximum functional capacity in performing Activities of Daily Living.”
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.”
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:
  • Meet the following conditions:
    • Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;
    • Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;
    • Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;
    • Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available; statewide; and
    • Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.
  • “Medically necessary” or “medical necessity” for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.
  • The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.”
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.”
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:
  • It is reasonably calculated to prevent, diagnose, or treat conditions in the participant that endanger life, cause pain, or cause functionally significant deformity or malfunction; and
  • There is no other equally effective course of treatment available or suitable for the participant requesting the service which is more conservative or substantially less costly.
  • Medical services must be of a quality that meets professionally-recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality. Those records must be made available to the Department upon request.”
Idaho requires prior authorization for the following list of services:
  • Transportation through AMR for non-emergency medical services.
  • Some medical equipment and supplies.
  • Home and Community-Based Waiver Services.
  • Some inpatient and outpatient hospitalizations or medical procedures.
  • Some vision services.
  • Some dental services.
  • Personal care services.
  • Private duty nursing.
  • Physical, occupational, and speech therapy – beyond service limits.
  • Some medicines and most brand name drugs when generics are available.
  • Developmental disability agency services.
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.”
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:
  1. Be consistent with the diagnosis and treatment of the patient’s condition.
  2. Be in accordance with standards of good medical practice.
  3. Be required to meet the medical need of the patient and be for reasons other than the convenience of the patient or the patient’s practitioner or caregiver.
  4. Be the least costly type of service which would reasonably meet the medical need of the patient.
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:
  • “Authority.” The health intervention is recommended by the treating physician and is determined to be necessary by the state or the state’s designee.
  • “Purpose.” The health intervention has the purpose of treating a medical condition.
  • “Scope.” The health intervention provides the most appropriate supply or level of service, considering potential benefits and harms to the patient.
  • “Evidence.” The health intervention is known to be effective in improving health outcomes. For new interventions, effectiveness shall be determined by scientific evidence as provided herein. For existing interventions, effectiveness shall be determined as provided in paragraph i.
  • “Value.” The health intervention is cost-effective for this condition compared to alternative interventions, including no intervention. “Cost-effective” shall not necessarily be construed to mean lowest price. An intervention may be medically indicated and yet not be a covered benefit or meet this regulation’s definition of medical necessity.” Interventions that do not meet this regulation’s definition of medical necessity may be covered at the choice of the state or the state’s designee. An intervention shall be considered cost effective if the benefits and harms relative to costs represent an economically efficient use of resources for patients with this condition. In the application of this criterion to an individual case, the characteristics of the individual patient shall be determinative.
Kansas statutes also add that KAN Be Healthy services (see pgs. 60-61) also include:
  • “Other necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the [KAN Be Healthy] screening services.
Kentucky According to the Kentucky Administrative Regulations, to be medically necessary or a medical necessity, a covered benefit shall be:

  1. Reasonable and required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition; including pregnancy;
  2. Appropriate in terms of the service, amount, scope, and duration based on generally-accepted standards of good medical practice;
  3. Provided for medical reasons rather than primarily for the convenience of the individual, the individual’s caregiver, or the health care provider, or for cosmetic reasons;
  4. Provided in the most appropriate location, with regard to generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and effectively provided;
  5. Needed, if used in reference to an emergency medical service, to exist using the prudent layperson standard;
  6. Provided in accordance with early and periodic screening, diagnosis, and treatment (EPSDT) requirements established in 42 U.S.C 1396d(r) and 42 C.F.R. Part 441 Subpart B for individuals under twenty-one (21) years of age; and
  7. Provided in accordance with 42 C.F.R. 440.230.
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:
  • Medically necessary services are defined as those health care services that are in accordance with generally accepted evidence-based medical standards or that are considered by most physicians (or other independent licensed practitioners) within the community of their respective professional organizations to be the standard of care.
  • In order to be considered medically necessary, services must be:
    • Deemed reasonably necessary to diagnose, correct, cure, alleviate or prevent the worsening of a condition or conditions that endanger life, cause suffering or pain or have resulted or will result in a handicap, physical deformity or malfunction.
    • Those for which no equally effective, more conservative and less costly course of treatment is available or suitable for the recipient.
  • Any such services must be individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment and neither more nor less than what the recipient requires at that specific point in time.
  • Although a service may be deemed medically necessary, it doesn’t mean the service will be covered under the Medicaid program. Services that are experimental, non-FDA approved, investigational or cosmetic are specifically excluded from Medicaid coverage and will be deemed “not medically necessary”.
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.

Maine’s Medicaid Benefits Manual defines “medically necessary services” as those that are:

  1. Provided in an appropriate setting;
  2. Recognized as standard medical care, based on national standards for best practices and safe, effective, quality care;
  3. Required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being;
  4. MaineCare (Medicaid) covered services (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Prevention, Health Promotion and Optional Treatment requirements as detailed in Chapter ll, Section 94 of this Manual)’
  5. Performed by enrolled providers within their scope of licensure and/or certification; and
  6. Provided within the regulations of the Manual.
Under the Code of Maryland Regulations, “Medically necessary” means that the service or benefit is:
  1. Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;
  2. Consistent with current accepted standards of good medical practice;
  3. The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and
  4. Not primarily for the convenience of the consumer, the consumer’s family, or the provider.
No information at this time.
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.”
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:
  • Is recognized as the prevailing standard or current practice by the provider’s peer group; and
  • Is rendered in response to a life threatening condition or pain; or to treat an injury, illness, or infection; or to treat a condition that could result in physical or mental disability; or to care for the mother and child through the maternity period; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition; or
  • Is a preventive health service “provided to a recipient to avoid or minimize the occurrence of illness, infection, disability, or other health condition.”

The Administrative Rules describe EPSDT services using the federal definition.

Mississippi
Mississippi’s Medicaid provider policy manual defines “medically necessary services” as those that are
  • Appropriate and consistent with the diagnosis of the treating provider and the omission of which could adversely affect the patient’s medical condition; and
  • Compatible with the standards of acceptable medical practice in the United States; and
  • Provided in a safe, appropriate and cost-effective setting given the nature of the diagnosis and the severity of the symptoms; and
  • Not provided solely for the convenience of the beneficiary or the family, or the convenience of any health care provider; and
  • Not primarily custodial care; and
  • There is no other effective and more conservative or substantially less costly treatment service and setting available; and
  • The service is not experimental, investigational or cosmetic in nature.
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.”
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:
  • Which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions in a patient which:
    • endanger life;
    • cause suffering or pain;
    • result in illness or infirmity;
    • threaten to cause or aggravate a handicap; or
    • cause physical deformity or malfunction.
  • A service or item is not medically necessary if there is another service or item for the recipient that is equally safe and effective and substantially less costly including, when appropriate, no treatment at all.
  • Experimental services or services which are generally regarded by the medical profession as unacceptable treatment are not medically necessary for purposes of the Montana Medicaid program.
    • Experimental services are procedures and items, including prescribed drugs, considered experimental or investigational by the U.S. Department of Health and Human Services, including the Medicare program, or the department’s designated review organization or procedures and items approved by the U.S. Department of Health and Human Services for use only in controlled studies to determine the effectiveness of such services.”
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 –

  1. Necessary to meet the basic health needs of the client;
  2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;
  3. Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;
  4. Consistent with the diagnosis of the condition;
  5. Required for means other than convenience of the client or his or her physician;
  6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
  7. Of demonstrated value; and
  8. No more intense level of service than can be safely provided.”
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:
  • Type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies.
  • Level of service that can be safely and effectively furnished, and for which no equally effective and more conservative or less costly treatment is available.
  • Services are delivered in the setting that is clinically appropriate to the specific physical and mental/behavioral health care needs of the recipient.
  • Services are provided for medical or mental/behavioral reasons rather than for the convenience of the recipient, the recipient’s caregiver, or the health care provider.”
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. “
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:
  1. Clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms;
  2. Not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider;
  3. No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient’s illness, injury, disease, or its symptoms; and
  4. Not experimental, investigative, cosmetic, or duplicative in nature.”
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.”
In New Mexico, medically necessary services are defined in regulation as clinical and rehabilitative physical or behavioral health services that:
  • Are essential to prevent, diagnose or treat medical conditions or are essential to enable the individual to attain, maintain or regain functional capacity;
  • Are delivered in the amount, duration, scope and setting that is clinically appropriate to the specific physical, mental and behavioral health care needs of the individual;
  • Are provided within professionally accepted standards of practice and national guidelines; and
  • Are required to meet the physical and behavioral health needs of the individual and are not primarily for the convenience of the individual, the provider or the payer”

The state does not have distinct definitions for children, oral health services, or behavioral health services.

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.
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.”
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.”
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:
  1. Meet generally accepted standards of medical practice;
  2. Be appropriate to the illness or injury for which it is performed as to type of service and expected outcome;
  3. Be appropriate to the intensity of service and level of setting;
  4. Provide unique, essential, and appropriate information when used for diagnostic purposes;
  5. Be the lowest cost alternative that effectively addresses and treats the medical problem; and
  6. Meet general principles regarding reimbursement for Medicaid covered services found in rule 5101:3-1-02 of the Administrative Code.”
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:

  1. Consistent with the symptoms of a health condition or treatment of a health condition;
  2. Appropriate with regard to standards of good health practice and generally recognized by the relevant scientific community, evidence-based medicine and professional standards of care as effective;
  3. Not solely for the convenience of an OHP client or a provider of the service or medical supplies; and
  4. The most cost effective of the alternative levels of medical services or medical supplies which can be safely provided to a Division client or Primary Care Manger (PCM) Member in the PHP’s or PCM’s judgment.
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.”
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:
  1. It is consistent with the recipient’s symptoms, diagnosis, condition, or injury;
  2. It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider’s peer group;
  3. It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition;
  4. It is not furnished primarily for the convenience of the recipient or the provider; and
  5. There is no other equally effective course of treatment available or suitable for the recipient requesting the service which is more conservative or substantially less costly.”
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:
  1. It must be required in order to diagnose or treat an enrollee’s medical condition. The convenience of an enrollee, the enrollee’s family, or a provider, shall not be a factor or justification in determining that a medical item or service is medically necessary;
  2. It must be safe and effective. To qualify as safe and effective, the type and level of medical item or service must be consistent with the symptoms or diagnosis and treatment of the particular medical condition, and the reasonably anticipated medical benefits of the item or service must outweigh the reasonably anticipated medical risks based on the enrollee’s condition and scientifically supported evidence;
  3. It must be the least costly alternative course of diagnosis or treatment that is adequate for the medical condition of the enrollee. When applied to medical items or services delivered in an inpatient setting, it further means that the medical item or service cannot be safely provided for the same or lesser cost to the person in an outpatient setting. Where there are less costly alternative courses of diagnosis or treatment, including less costly alternative settings, that are adequate for the medical condition of the enrollee, more costly alternative courses of diagnosis or treatment are not medically necessary. An alternative course of diagnosis or treatment may include observation, lifestyle or behavioral changes or, where appropriate, no treatment at all; and
  4. It must not be experimental or investigational. A medical item or service is experimental or investigational if there is inadequate empirically-based objective clinical scientific evidence of its safety and effectiveness for the particular use in question. This standard is not satisfied by a provider’s subjective clinical judgment on the safety and effectiveness of a medical item or service or by a reasonable medical or clinical hypothesis based on an extrapolation from use in another setting or from use in diagnosing or treating another condition”
Texas
Under the Texas Administrative Code, medically necessary means:
“For Medicaid members birth through age 20, the following Texas Health Steps services:
  • screening, vision, dental, and hearing services; and
  • other health care services or dental services that are necessary to correct or ameliorate a defect or physical or mental illness or condition. A determination of whether a service is necessary to correct or ameliorate a defect or physical or mental illness or condition:
    • must comply with the requirements of a final court order that applies to the Texas Medicaid program or the Texas Medicaid managed care program as a whole;”
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:
  • provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s health conditions;
  • consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;
  • consistent with the member’s diagnoses;
  • no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
  • not experimental or investigative; and
  • not primarily for the convenience of the member or provider.
For behavioral health services, that services:
  • are in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;
  • are furnished in the most appropriate and least restrictive setting in which services can be safely provided;
  • are the most appropriate level or supply of service that can safely be provided;
  • could not be omitted without adversely affecting the member’s mental and/or physical health or the quality of care rendered;
  • are not experimental or investigative; and are not primarily for the convenience of the member or provider.
No information at this time.
No information at this time.
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:
  • “Assuring that health concerns are diagnosed as early as possible,
  • Assuring that treatment is provided before problems become complex, and
  • Assuring that medically justified services are provided to treat or correct identified problems”
The guide adds that “all requests for EPSDT treatment services must:
  • Be deemed medically necessary to correct or ameliorate a health or mental health condition; and,
  • Have the need for specialist referral or treatment documented during an EPSDT screening.
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).”
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.”
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:
  1. Is consistent with the recipient’s symptoms or with prevention, diagnosis or treatment of the recipient’s illness, injury or disability;
  2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided;
  3. Is appropriate with regard to generally accepted standards of medical practice;
  4. Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms or other medically necessary services being provided to the recipient;
  5. Is of proven medical value or usefulness and, consistent with s. DHS 107.035, is not experimental in nature;
  6. Is not duplicative with respect to other services being provided to the recipient;
  7. Is not solely for the convenience of the recipient, the recipient’s family or a provider;
  8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and
  9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient.”
Wyoming
Wyoming Rules and Regulations define Medical Necessity for the Health Check program as follows:
  • “Medically necessary.” A health service that is required to diagnose, treat, cure or prevent illness, injury or disease which has been diagnosed or is reasonably suspected, to relieve pain or to improve and preserve health and be essential to life. The services must be:
    • Consistent with the diagnosis and treatment of the recipient’s condition;
    • Recognized as the prevailing standard or current practice among the provider’s peer group;
    • Required to meet the medical needs of the recipient and undertaken for reasons other than the convenience of the recipient and the provider; and
    • Provided in the most efficient manner and/or setting consistent with appropriate care required by the recipient’s condition.

 

 

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