What is considered "medically necessary" in health insurance?

The term "medically necessary" in health insurance refers to services that are deemed appropriate for diagnosing or treating a medical condition. This definition emphasizes that for a service to be classified as medically necessary, it must not only relate to the treatment of a health issue but also be appropriate in terms of accepted medical standards.

Health insurers generally evaluate the necessity of medical services based on several criteria, including whether the service is effective, whether it is the least restrictive service required, and whether it addresses a specific medical condition rather than being for convenience or personal preference.

Services that are optional for treatment do not fall under this definition, as they are not essential for addressing a medical condition. Similarly, any service provided by a healthcare professional may not necessarily be considered medically necessary if it does not meet the criteria for appropriateness and necessity. Lastly, while some services might require prior authorization, this requirement alone does not determine whether a service is medically necessary; it is merely a procedural step prior to approval for those services deemed necessary.