Medically Necessary or Medical Necessity

"Medically Necessary" are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a member for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

• in accordance with generally accepted standards of medical practice; and

• clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the member's illness, injury or disease; and

• not primarily for the convenience of the member, physician 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 member'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, physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.

NOTE: For TennCare purposes, Medical Necessity and Medically Necessary are defined by Public Necessity Rules of the Tennessee Department of Finance and Administration, Bureau of TennCare, Chapter 1200-13-16 Medical Necessity.

This document has been classified as public information.