Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
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Appendix G: Medical Necessity
Appendix G: Medical Necessity
Pages 225-232
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From page 225... ...
Medical Purpose • A health intervention for the purpose of treating a medical condition -- a research project at Stanford further defined a health intervention as an item or service delivered or undertaken primarily to treat (i.e., prevent, diagnose, detect, treat, palliate) a medical condition (i.e., disease; illness; injury; genetic or congenital defect; pregnancy; biological or psychological condition that lies outside the range of normal, age-appropriate human variation)
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From page 226... ...
) • Screening and diagnostic services to determine physical or mental defects in recipients under age 21; and health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered1 • For the diagnosis, cure, mitigation, treatment, or prevention of disease or for the purpose of affecting any structure or function of the body2 • Health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition, or prevent a medical condition from occurring3 • For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member4 • 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 handicap5 Scope • Clinically appropriate in terms of type, frequency, extent, site, and duration (AMA, 2005)
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From page 227... ...
• In accordance with standards of medical practice that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas and any other relevant factors (Bocchino, 2010) • Known to be effective in improving health outcomes.
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From page 228... ...
not primarily for the convenience of the patient, physi cian or other health care provider, and 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. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgment.
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From page 229... ...
If controlled clinical trials are not available, observational studies that demonstrate a causal relationship between the intervention and health outcomes can 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.
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From page 230... ...
10 (State of Connecticut Department of Social Services) : Health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition or prevent a medical condition or prevent a medical condition from occurring.
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From page 231... ...
2010. Online questionnaire responses submitted by Michael Maves, Chief Executive Officer and Executive Vice President, American Medical Association to the IOM Committee on the Determination of Essential Health Benefits, December 20.
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