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Medically necessary or medical necessity
Alert: The provider or patient must provide documentation demonstrating medical necessity when requested by the plan, or services may be denied as not medically necessary. Some services that are medically necessary may not be covered by the plan. All benefits or services that are medically necessary are subject to the coverage limitations, exclusions, and provisions of the plan. It is important to review your certificate of coverage or verify coverage before receiving services by calling UMP Customer Service at:
- UMP (PEBB): 1-888-849-3681 (TRS: 711)
- UMP (SEBB): 1-800-628-3481 (TRS: 711)
Medically necessary or medical necessity means health care services, supplies, prescription drugs, or interventions that a treating licensed health care provider recommends and all the following conditions are met:
- The purpose of the service, supply, intervention, or drug is to treat or diagnose a medical condition.
- It is the appropriate level of service, supply, or intervention, or prescription drug dose considering the potential benefits and harm to the patient.
- The level of service, supply, intervention, or prescription drug dose is known to be effective in improving health outcomes.
- The level of service, supply, intervention, or prescription drug recommended for this condition is cost-effective compared to alternative interventions, including no intervention.
- For services that have been reviewed by the Health Technology Clinical Committee (HTCC), the HTCC’s coverage conditions are met.
The fact that a physician or other provider prescribes, orders, recommends, or approves a service or supply, prescription drug, or drug dose does not, in itself, make it medically necessary.
The plan may require proof that services, interventions, supplies, or prescription drugs (including court-ordered care) are medically necessary. No benefits will be provided if the proof is not received or is not acceptable, or if the service, supply, prescription drug, or drug dose is not medically necessary. Claims processing may be delayed if proof of medical necessity is required but not provided by the health service provider.
The plan uses scientific evidence from peer-reviewed medical literature to determine effectiveness for services and interventions not yet in widespread use for the medical condition and patient indications being considered. State law requires that UMP determine whether a service or intervention is covered based on decisions made by the Health Technology Clinical Committee (HTCC). These decisions may be referenced on the Health Technology reviews webpage. If the HTCC determines that a health technology (service) will be covered only under certain conditions, the plan is required by law to use the HTCC coverage criteria when evaluating whether the service is medically necessary. If the HTCC determines that a service will not be covered, then the service is considered to be not medically necessary by the plan.
The plan uses scientific evidence from peer-reviewed medical literature to determine effectiveness for services and interventions not yet in widespread use for the medical condition and patient indications being considered.
For health technologies that have been reviewed by the HTCC and are covered with limitations, the plan uses the HTCC’s coverage criteria to determine medical necessity. For other services, interventions, or supplies the plan first uses scientific evidence, then professional standards, then expert opinion to determine effectiveness. “Effective” means that the prescription drug, drug dose, intervention, supply, or level of service mayreasonably be expected to produce the intended results and to have expected benefits that outweigh potential harmful effects. The scientific evidence should be considered first and, to the greatest extent possible, should be the basis for determining medical necessity. If no scientific evidence is available, professional United States (U.S.) standards of care should be considered. If professional standards of care do not exist, or are outdated or contradictory, decisions about interventions should be based on expert opinion.
Giving priority to scientific evidence does not mean that the plan should deny coverage of interventions in the absence of conclusive scientific evidence. Interventions may meet the plan’s definition of medical necessity in the absence of scientific evidence if there is a strong conviction of effectiveness and benefit expressed through up-to-date and consistent professional standards of care, or, in the absence of such standards, convincing expert opinion.
A level of service, supply, prescription drug, or intervention is considered “cost effective” if the benefits and harms relative to the costs represent an economically efficient use of resources for the patients with this condition. The plan applies this criterion based on the characteristics of the individual patient. Cost-effective does not necessarily mean the lowest price.
Preventive services not covered by the plan’s preventive care benefit will still be covered under the medical benefit if medically necessary.
A “health intervention” is an item or service delivered or undertaken primarily to prevent, diagnose, detect, treat, or palliate a medical condition (such as a disease, illness, injury, genetic or congenital defect, pregnancy, or a biological or psychological condition that lies outside the range of normal, age-appropriate human variation) or to maintain or restore functional ability. For purposes of this definition of “medical necessity” the plan does not consider a health intervention separately from the medical condition and patient indications it is applied to.
“Treating provider” means a licensed health care provider who has personally evaluated the patient.
“Health outcomes” are results that affect health status as measured by the length or quality (primarily as perceived by the patient) of a person’s life.
Scientific evidence consists primarily of controlled clinical trials that either directly or indirectly demonstrate the effect of the intervention on health outcomes. If controlled clinical trials are not available, observational studies that demonstrate a causal relationship between the intervention and health outcomes may be used. Partially controlled observational studies and uncontrolled clinical series may be suggestive, but do not by themselves demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or potential experimental biases.
Interventions for which clinical trials have not been conducted because of epidemiological reasons (that is, rare or new diseases or orphan populations) shall be evaluated based on professional standards of care or expert opinion.