Physician Based Medical Necessity Determination

Physician Based Medical Necessity Determination

A physician-based determination of medical necessity, except where state law or regulation requires a different standard, is a medical opinion based on evidence-based clinical standards of care and prudent clinical judgment, which indicate the necessity of medical services:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
  3. 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 that patient’s illness, injury, or disease