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Medical Necessity in Private Health Plans
Table 6. Medical Necessity Definitions: State Insurance Laws and IRO Statutes
| State |
Medical Necessity Definition in Insurance Content Statutes |
IRO Statute (Y/N) |
Medical Necessity Definition in IRO Statute |
IRO Statute Definition |
| Alabama |
N |
N |
|
|
| Alaska
|
N
|
Y
|
N |
|
| Arizona
|
N
|
Y
|
N |
|
| Arkansas
|
Y
|
N |
|
|
| California
|
Y
|
Y
|
N |
|
| Colorado
|
N
|
Y
|
N |
|
| Connecticut
|
N
|
Y
|
N |
|
| Delaware |
N |
Y |
Y |
For the purpose of this act, "medical necessity" means the providing of
covered health services or products that a prudent physician would provide
to a patient for the purpose of diagnosing or treating an illness, injury,
or disease or its symptoms, in a manner that is: (1) In accordance with
the generally accepted standards of medical practice; (2) Consistent with
the symptoms or treatment of the condition; and (3) Not solely for anyone's
convenience. 16 Del. Code § 9119 (2000) |
| District of Columbia
|
N
|
Y
|
N |
|
| Florida
|
Y
|
Y
|
N |
|
| Georgia |
N |
Y |
Y |
(5) "Medical necessity," "medically necessary care," or "medically necessary
and appropriate" means care based upon generally accepted medical practices
in light of conditions at the time of treatment which is: (A) Appropriate
and consistent with the diagnosis and the omission of which could adversely
affect or fail to improve the eligible enrollee's condition; (B) Compatible
with the standards of acceptable medical practice in the United States;
(C) Provided in a safe and appropriate setting given the nature of the diagnosis
and the severity of the symptoms; (D) Not provided solely for the convenience
of the eligible enrollee or the convenience of the health care provider
or hospital; and (E) Not primarily custodial care, unless custodial care
is a covered benefit under the eligible enrollee's evidence of coverage.
O.C.G.A. § 33-20A-31 (2000) |
| Hawaii |
N |
Y |
Y |
Medical necessity (b) A health intervention is medically necessary if
it is recommended by the treating physician or treating licensed health
care provider, is approved by the health plan's medical director or physician
designee, and is: (1) For the purpose of treating a medical condition; (2)
The most appropriate delivery or level of service, considering potential
benefits and harms to the patient; (3) Known to be effective in improving
health outcomes; provided that: (A) Effectiveness is determined first by
scientific evidence; (B) If no scientific evidence exists, then by professional
standards of care; and (C) If no professional standards of care exist or
if they exist but are outdated or contradictory, then by expert opinion;
and (4) Cost-effective for the medical condition being treated compared
to alternative health interventions, including no intervention. For the
purposes of this paragraph, cost-effective shall not necessarily mean lowest
price. HRS § 432E-1.4 (2000) |
| Idaho
|
N
|
N |
|
|
| Illinois
|
Y
|
Y
|
N |
|
| Indiana
|
Y
|
Y
|
N |
|
| Iowa
|
N
|
Y
|
Y
|
Medical necessity is defined as the insurer's plan defines it. Iowa Code 514J.5 |
| Kansas
|
N
|
Y
|
N |
|
| Kentucky
|
N
|
Y
|
N |
|
| Louisiana
|
N
|
Y
|
N |
|
| Maine |
N |
Y |
Y |
"Medically necessary health care" means health care services or products
provided to an enrollee for the purpose of preventing, diagnosing or treating
an illness, injury or disease or the symptoms of an illness, injury or disease
in a manner that is (A) consistent with generally accepted standards of
medical practice; (B) clinically appropriate in terms of type, frequency,
extent, site and duration; (C) demonstrated through scientific evidence
to be effective in improving health outcomes; (D) representative of "best
practices" in the medical profession; and (E) not primarily for the convenience
of the enrollee or physician or other health care practitioner. 24-A MRSA
§ 4301-A(10-A). |
| Maryland
|
Y
|
Y
|
N |
|
| Massachusetts |
N |
Y |
Y |
"Medical necessity" or "medically necessary," health care services that
are consistent with generally accepted principles of professional medical
practice. Mass. Ann. Laws ch. 176O (1) (2001) |
| Michigan
|
N
|
Y
|
N |
|
| Minnesota
|
Y
|
Y
|
N |
|
| Mississippi
|
N
|
N |
|
|
| Missouri
|
N
|
Y
|
N |
|
| Montana
|
N
|
Y
|
N |
|
| Nebraska
|
N
|
N |
|
|
| Nevada
|
N
|
N |
|
|
| New Hampshire
|
N
|
Y
|
N |
|
| New Jersey
|
N
|
Y
|
N |
|
| New Mexico
|
N
|
Y
|
N |
|
| New York
|
N
|
Y
|
N |
|
| North Carolina
|
Y
|
Y
|
N |
|
| North Dakota
|
N
|
N |
|
|
| Ohio
|
N
|
Y
|
N |
|
| Oklahoma
|
N
|
Y
|
N |
|
| Oregon
|
N
|
Y
|
N |
|
| Pennsylvania
|
N
|
Y
|
N |
|
| Rhode Island
|
N
|
Y
|
N |
|
| South Carolina
|
N
|
Y
|
N |
|
| South Dakota
|
N
|
N |
|
|
| Tennessee
|
N
|
Y
|
N |
|
| Texas
|
N
|
Y
|
N |
|
| Utah
|
N
|
Y
|
N |
|
| Vermont
|
N
|
Y
|
N |
|
| Virginia |
N |
Y |
Y |
"Medical necessity" or "medically necessary" means appropriate and necessary
health care services which are rendered for any condition which, according
to generally accepted principles of good medical practice, requires the
diagnosis or direct care and treatment of an illness, injury, or pregnancy-related
condition, and are not provided only as a convenience. Va. Code Ann. § 38.2-5800
(2001) |
| Washington
|
N
|
Y
|
N |
|
| West Virginia
|
N
|
Y
|
N |
|
| Wisconsin
|
N
|
N |
|
|
| Wyoming
|
N
|
N |
|
|
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