Medical necessity standard


AZBH | CA | CO | CT | DE | FL | FLMH | HI | IA | IABH | KS | KY | ME | MD | MA | MN | MO | MT | NE | NEBH


NV | NY | ND | OH | OK | ORMH | PA | PABH | RI | SC | TN | TX | UT | UTMH | VA | WA | WV | WI



AZBH

MEDICALLY NECESSARY SERVICES
Those covered services provided by qualified service providers within the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life."  Arizona Behavioral Health Contract, page 6.

CA

ARTICLE II - DEFINITIONS...
D1. Medically Necessary means reasonable and necessary services to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness, or injury."  California Contract, pages 2, 9.

CO

I. DEFINITIONS
The following terms as used in this Contract shall be construed and interpreted as follows unless the context otherwise expressly requires a different construction and interpretation: ...

AV.  'Medically Necessary':  A Covered Service shall be deemed Medically Necessary if, in a manner consistent with accepted standards of medical practice, it:
a.  is found to be an equally effective treatment among other, less conservative or more costly treatment options; and,
b.  meets at least one of the following criteria:
1.  The service will, or is reasonably expected to, prevent or diagnose the onset of an illness, injury, condition, primary Disability or Secondary Disability.
2.  The service will, or is reasonably expected to, cure, correct, reduce or ameliorate the physical, mental, cognitive or developmental effects of an illness, injury, or Disability.
3.  The service will, or is reasonably expected to, reduce or ameliorate the pain or suffering caused by an illness, injury, condition or Disability.
4.  The service will, or is reasonably expected to, assist the individual to achieve or maintain maximum functional capacity in performing Activities of Daily Living.
A course of treatment may include mere observation, or when appropriate, no treatment at all.  The Medical Necessity of a Covered Service shall be determined by the Contractor and the Member's Primary Care Physician, in consultation with the Member or Member's legal guardian."  Colorado Contract, pages 7-8.

CT

Part II:  General Contract Terms for MCOs
1.  Definitions...
EE.  Medically necessary/Medical necessity:  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 occurring…"  Connecticut Contract, pages 11-14.

DE

Appendix R

MEDICAL NECESSITY DEFINITION
MEDICAL NECESSITY is defined as:
the essential need for medical care or services (all covered State Medicaid Plan services, subject to age and eligibility restrictions and/or EPSDT requirements) which, when prescribed by the beneficiary's primary physician care manager and delivered by or through authorized and qualified providers, will:

- be directly related to the diagnosed medical condition or the effects of the condition of the beneficiary (the physical or mental functional deficits that characterize the beneficiary's condition) and be provided  to the beneficiary only;

-  be appropriate and effective to the comprehensive profile (e.g. needs, aptitudes, abilities and environment) of the beneficiary and the beneficiary's family;

-  be primarily directed to treat the diagnosed medical condition or the effects of the condition of the beneficiary, in all settings for normal activities of daily living, but will not be solely for the convenience of the beneficiary, the beneficiary's family, or the beneficiary's provider (this means that services which are primarily used for educational, vocational, social, recreational, or other non-medical purposes are not covered under the Medicaid program);

-  be timely, considering the nature and current state of the beneficiary's diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time;

-  be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds;

-  be the most appropriate, available health service alternative, and will represent an effective and appropriate use of program funds;

-  be sufficient in amount, scope, and duration to reasonably achieve its purpose;

-  be recognized as either the treatment of choice (i.e. prevailing community or statewide standard) or common medical practice by the practitioner's peer group, or the functional equivalent of other care and services that are commonly provided;

-  be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has resulted in or could result in a physical or mental limitation, including loss of physical or mental functionality or developmental delay;

and will be reasonably determined to:

-  diagnose, cure, correct or ameliorate defects and physical and mental illnesses and diagnosed conditions or the effects of such conditions; or

-  restore or improve physical or mental functionality, including developmental functioning, lost or delayed as the result of an illness, injury, or other diagnosed condition or the effects of the illness, injury, or condition or

-  provide assistance in gaining access to needed medical, social, educational and other services required to diagnose, treat, or support a diagnosed condition or the effects of the condition,

in order that

the beneficiary might attain or retain independence, self-care, dignity, self-determination, personal safely, and integration into all natural family, community and facility environments and activities."  Delaware RFP, Appendix R, pages R.1-R.2.

FL

47.  Medically Necessary or Medical Necessity - services provided in accordance with 42 CFR Section 440.230 to include that medical or allied care, good, or services furnished or ordered must:

(a) Meet the following conditions:
1.  Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;
2.  Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, as not in excess of the patient's needs;
3.  Be consistent with the generally accepted professional medical standards as determined by the Medicaid program, and not experimental or Investigational;
4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available, statewide; and
5.  Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

(b) 'Medically necessary' or 'medical necessity' for inpatient hospital services requires that those services furnished in a hospital on an impatient basis could not, consistent with the provisions of appropriate medical care, effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.

(c) The fact that a provider has prescribed, recommended, or approved medical or allied goods, or services does not, in itself, miss such care, goods or services medically necessary or a medical necessity or a covered service."  Florida Contract, pages 156-157.

FLMH

"YY.  Medically Necessary - The requirement that the goods and services provided or ordered must be:
1. Calculated to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity;
2. Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient's needs;
3.  Necessary and consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;
4.  Reflective of the level of service that can be safely provided, and for which no equally effective and more conservative or less costly treatment is available; and
5. Provided in a manner not primarily  intended for the convenience of the recipient, the recipient's caretaker, or the provider."  Florida Mental Health RFP, pages 16-17.

HI

HEALTH  INTERVENTIONS
1.  Health plans are required to cover health interventions within the specified categories that meet the following criteria:
 a.  The intervention must be used for a medical condition.
b.  There is sufficient evidence to draw conclusions about the intervention's effects on health outcomes.
c.  The evidence demonstrates that the intervention can be expected to produce its intended effects on health outcomes.
d.  The interventions' beneficial effects on health outcomes outweigh its expected harmful effects.
e.  The health intervention is the most cost-effective method available to address the medical condition…"  Hawaii RFP, Appendix B, page 1.

"Organ and Tissue Transplantation
A.  For Adults...
2.  Covered transplants must be medically necessary for the recipient...
Criteria for medically necessity include but are not limited to the following:
a.  The medical condition of the patient is serious, not reversible and unresponsive to other medical or surgical therapy.
b.  The disease process is life-threatening and the prognosis for survival without transplantation is very poor.
c.  There is significant reason to believe that the transplant will improve the quality of life of the patient.
d.  There is significant reason to believe that the patient's medical status is adequate to tolerate the transplant procedure and follow-up medical and surgical care.
e.  The initial or primary disease process is confined to the organs or tissues to be transplanted with no life threatening involvement of other organ systems and no anticipation that life threatening recurrence of the disease process will involve the transplanted organs or tissues or any other organ system."  Hawaii RFP, Appendix F, page 14..

IA

1.3  Definitions...
- Medically Necessary Services - those services covered by the Medicaid program which:  (a) are essential to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or aggravate a handicap, or result in illness or infirmity of an Enrollee; (b) are provided at an appropriate level of care for the treatment of an Enrollee's medical condition; and, (c) are provided in accordance with generally accepted standards of medical practice.  Excluded are those services which would not be covered by Medicaid including those excluded by IAC 441--79.9."  Iowa Contract, pages 6, 9.

IABH

Service Necessity:  The requirement that goods and services provided or ordered must be, pursuant to the criteria of the ASAM PPC2, the IJPC, or the PMIC Admission and Continued Stay Criteria, which ever is applicable:
*  appropriate and necessary to the symptoms, diagnoses or treatment of a covered disorder
*  provided for the diagnosis or direct care and treatment of a covered disorder
*  within  standards of good practice within the substance abuse service area
*  required to meet the need related to a covered diagnosis or disorder, and not primarily for the convenience of the eligible person or provider
*  be the least costly type of service which would reasonably meet the need of the eligible person
*  be within the scope of the licensure of the provider"  Iowa Behavioral Health Contract, page 51.

KS

Medically Appropriate (Necessary) - services and medical supplies which are required for prevention, diagnosis, or treatment for sickness or injury which are:  (1) consistent with the symptoms of a medical condition or treatment of a medical condition; (2) appropriate with regard to standards of good medical practice and generally recognized by the medical scientific community as effective; (3) not solely for the convenience of an HMO member or a provider of the service or medical supplies; and (4) the most effective of the alternative levels of service or medical supplies which can safely be provided."  Kansas Contract, Appendix E, page 4.

KY

Medically Necessary Health Services means age appropriate services reasonable and necessary to diagnose and provide preventive, palliative, curative or restorative treatment for physical or mental conditions in accordance with professionally recognized standards of health care generally accepted at the time services are provided, and in accordance with 42 C.F.R. §440.230, including services for children authorized under 42 U.S.C. 1396d(r)." Kentucky Contract, page 14.

"Kentucky Medicaid covers only medically necessary services."  Kentucky RFA, Attachment VIII, page 62.

ME

II.  DEFINITIONS.
A.  The following terms used in this Contract shall be interpreted as defined herein, except to the extent that the context may clearly require otherwise: ...
40.  Medical Necessity is defined as health care services that are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness, or injury."  Maine Contract, pages 2, 7.

MD

Chapter 62  Maryland Medicaid Managed Care Program:  Definitions
.01  Definitions…
(94)  'Medically appropriate' means an effective service that can be provided, taking into consideration the particular circumstances of the recipient and the relative cost of any alternative services which could be used for the same purpose.

(95)  'Medically necessary' means directly related to diagnostic, preventive, curative, palliative, or rehabilitative treatment.

(96)  'Medically necessary and appropriate' means medically necessary and medically appropriate.

(97)  'Medical necessity' means what is medically necessary and appropriate."  Maryland COMAR 10.09.62.01.

MA

SECTION 1.  DEFINITION OF TERMS...
Medically Necessary - those services (1) which are reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the Enrollee that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability, or result in illness or infirmity; and (2) for which there is no comparable medical service or site of service available or suitable for the Enrollee requesting the service that is more conservative or less costly; and (3) are of a quality that meets generally accepted standards of health care…"  Massachusetts Contract, pages 6-13.

MN

Section 2.32. Medically Necessary or Medical Necessity means, pursuant to Minnesota Rules, Part 9505.0175, Subpart 25, a health service that is consistent with the Enrollee's diagnosis or condition and:

A.  is recognized as the prevailing standard or current practice by the provider's peer group; and

B.  is rendered in response to a life threatening condition or pain; or to treat an injury, illness or infection; or to treat a condition that could result in physical or mental disability; or to care for the mother through the maternity period; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition; or

C. is a preventive health service defined under Minnesota Rules, Part 9505.0355."  Minnesota Contract, pages 13-14.

MO

Medically necessary:  It is the responsibility of the health plan to determine whether or not a service(s) furnished or proposed to be furnished is (are) reasonable and medically necessary for the diagnosis or treatment of illness or injury, to improve the function of a malformed body member, or to minimize the progression of disability, in accordance with accepted standards of practice in the medical community of the area in which the health services are rendered; and service(s) could have been omitted without adversely affecting the member's condition or the quality of medical care rendered; and service(s) is (are) furnished in the most appropriate setting."  Missouri RFP, page 20.

MT

MEDICALLY NECESSARY OR MEDICALLY NECESSARY SERVICE- a service as defined at ARM 46.12.102(2) which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions in a patient which:
(a)  endanger life;
(b)  cause suffering or pain;
(c)  result in illness or infirmity;
(d)  threaten to cause or aggravate a handicap; or
(e)  cause physical deformity or malfunction.

A service or item is medically necessary only if there is no other equally effective, more conservative, or subsequently less costly course  of treatment medically appropriate for the RECIPIENT requesting the service or, or when appropriate, no treatment at all.  Experimental services or services generally regarded by the medical profession as unacceptable treatment are not necessary for purpose of the Medicaid program."  Montana Contract, pages 28-29.

NE

4.1.32 The term 'Medical Necessity', means health care services and supplies which are medically appropriate and (1) necessary to meet the basic health needs of the Client; (2) rendered in the most cost-effective manner and type of setting appropriate for the delivery of the Covered Services; (3) consistent in type, frequency and duration of treatment with scientifically based guidelines of national medical, research or health coverage organizations or governmental agencies; (4) consistent with the diagnosis of the condition; (5) required for reasons other than the convenience of the Client or his or her Physician; (6) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; (7) of demonstrated value; and (8) a no more intense level of services than can be safely provided. The fact that the Physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness or mental illness does not mean that it is Medically Necessary.  Services and supplies which do not meet the definition of medical necessity set out above are not covered."  Nebraska Contract, page 10.

NEBH

4.1  Applicable Definitions: The following definitions apply under this contract: ...
4.1.23 The term ‘Medical Necessity’ means health care services and supplies which are medically appropriate and:
(a)  Necessary to meet the basic health needs of the client;
(b) Rendered in the most cost-effective manner and type of setting appropriate for the delivery of the covered service;
(c) Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;
(d)   Consistent with the diagnosis of the condition;
(e)   Required for means other than convenience of the client or his or her physician;
(d)  No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
(e)  Of demonstrated value; and
(f)   No more intense level of service than can be safely provided.

The fact, that a provider has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid."  Nebraska Behavioral Health Contract, page 8.

"11.49  Application of Medical Necessary:  The PHP shall provide training for providers on the NHC policy, procedures, levels of treatment and application of medical necessity and develop outcome based monitoring and reporting processes that will assist the Department, or its designated entity, in the determination of appropriateness of the PHP’s service delivery system, and systems of care."  Nebraska Behavioral Health Contract, page 62.

NV

Medically Necessary Service:  To be considered medically necessary, items and services must have been established as safe and effective.  The items and services must be:  consistent with the symptoms or diagnosis of the illness or injury under treatment; necessary and consistent with generally accepted professional medical standards (in other words, not still experimental or investigational); not furnished primarily for the convenience of the patient the attending physician, or to his/her physician or supplier; furnished at the most appropriate level which can be provided safely and effectively to the patient.  Medicaid will only cover items and services which are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.  Any service covered under Medicaid that is necessary to treat or ameliorate a defect, physical and mental illness, or a condition identified by an EPSDT screen, must be provided to EPSDT participants regardless of whether the service or item is otherwise included in the Medicaid State Plan."  Nevada Contact, page 18.

NY

1.  Definitions...
'Medically Necessary' means health care and services that are necessary to prevent, diagnose, manage or treat 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 handicap…"  New York Contract, pages 1-3-1-4.

ND

Medically Necessary Service - Medical care and treatment that is:
a.  Appropriate for symptoms present and is consistent with the diagnosis, if any;
b.  Provided according to generally accepted medical practice and professionally recognized standards;
c.  Not generally regarded as experimental or investigation; and
d.  Specifically allowed by the licensing laws which apply to the provider of the service."  North Dakota Contract, Attachment C, page 5.

OH

5101:3-26-01  Managed care plan:  Definitions.
As used in Chapter 5101:3-26 of the Administrative Code: …
(SS)  'Medical necessity' as used in this chapter is the same as defined in paragraph (A) of rule 5101:3-1-01 of the Administrative Code."  Ohio RFP, Appendix E, OAC 5101:3-26-01, page 4.

OK

1.4  Definitions
Each of the following terms shall have the indicated meanings unless the context clearly requires otherwise: ...

45. MEDICALLY NECESSARY SERVICE means covered medical, dental, behavioral, rehabilitative or other health care services which:
• are reasonable and necessary to prevent illness or medical conditions, or provide early screening, interventions, and/or treatment for conditions that cause suffering or pain, cause physical deformity or limitation in function, cause illness or infirmity, endanger life, or worsen a disability;
• are provided at appropriate facilities and at the appropriate levels of care for the treatment of a member's medical conditions;
• are consistent with the diagnoses of the conditions;
• are no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, efficiency and independence and
• will assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual, and those functional capacities that are appropriate for individuals of the same age…"  Oklahoma RFP, pages 5, 9.

ORMH

DEFINITIONS
With the following exceptions and additions, the terms in this agreement have the same definitions as those terms appearing in Oregon Administrative Rules(OARs)...
Appropriate: The extent to which a particular procedure, treatment, test, or service is documented to be effective, clearly indicated, not excessive, adequate in quantity, and provided in the setting best suited to the needs of the OMAP Member...

Medically Appropriate: Services and Supplies which are required for prevention(including preventing a relapse), Diagnosis and treatment of  mental disorders and which are Appropriate and consistent with the Diagnosis; consistent with treating the symptoms of a mental illness or treatment of a mental disorder; appropriate with regard to standards of good practice and generally recognized by the relevant scientific community as effective; not solely for the convenience of the OMAP Member or provider of the service or supply; and the most cost effective of the alternative levels of Covered Services or supplies which can be safely and effectively provided to the OMAP Member in the Contractor's judgement."  Oregon Mental Health Contract, Appendix K, pages K1,  K12.

PA

Medical Necessity-Determination of medical necessity for covered care and services, whether made on prior authorization, concurrent, or post authorization basis, shall be in writing, be comprehensible under MA, and be based on the following standards.  The plan shall base its determination on medical information provided by the individuals family and the primary care practitioner, as well as any other providers, programs, and agencies that have evaluated the individual.  Medical necessity determination must be made by qualified and trained providers.  Satisfaction of any one of the following standards will result in authorization of the service:
•  The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability.
•  The service or benefit will, or is reasonably expected to reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability.
•  The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking in to account both the functional capacities that are appropriate for individuals of the same age"  Pennsylvania RFP, pages x-xi.

PABH

Request for Proposals (RFP) Definitions
For the purpose of this Health Choices behavioral health services RFP, the definitions set forth shall apply...

Medical Necessity - Clinical determinations to establish a service or benefit which will, or is reasonably expected to:
  prevent the onset of an illness, condition, or disability;
  reduce or ameliorate the physical, mental behavioral, or developmental effects of an illness, condition, injury, or disability;
  assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities appropriate for individuals of the same age."  Pennsylvania Behavioral Health RFP, pages 3, 6.

RI

ARTICLE I:  DEFINITIONS...
1.14  MEDICAL NECESSITY OR MEDICALLY NECESSARY SERVICE
The term "medical necessity" or 'medically necessary service' means medical, surgical, or other services required for the prevention, diagnosis, cure, or treatment of a health related condition including such services necessary to prevent a decremental change in either medical or mental health status.  Medically necessary services must be provided in the most effective and appropriate setting and shall not be provided solely for the convenience of the member or service provider…"  Rhode Island RFP, pages 1, 3.

SC

4.1  Core Benefits For The South Carolina Medicaid HMO Program...
In the provision of core benefits services outlined and defined in Appendix C, Tab 1 the Contractor shall be required to provide medically necessary and appropriate care to Medicaid HMO Program members under this Contract. 'Medically necessary' services include, but are not limited to, services directed toward the maintenance, improvement, or protection of health or lessening of illness, disability, or pain. The SCDHHS shall make final interpretation of any disputes about the medical necessity and continuation of core benefits covered under this Contract based on whether or not the Medicaid fee-for-service program would have provided the service."  South Carolina Contract, pages 14-15.

"Medically Necessary Service - Those medical services which:  (a) are essential to prevent, diagnose, prevent the worsening of, alleviate, correct or cure medical conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or aggravate a handicap, or result in illness or infirmity of a Medicaid HMO Program member; (b) are provided at an appropriate facility and at the appropriate level of care for the treatment of Medicaid HMO Program member's medical condition; and, (c) are provided in accordance with generally accepted standards of medical practice."  South Carolina Contract, Appendix A, page 6.

TN

Attachment I - Definitions...
34.  Medically Necessary - shall mean  services or supplies provided by an institution, physician, or other provider that are required to identify or treat a TennCare enrollee's illness, disease, or injury and which are:
  a.  Consistent with the symptoms or diagnosis and treatment of the enrollee's illness, disease, or injury; and
  b.  Appropriate with regard to standards of good medical practice; and
  c.  Not solely for the convenience of an enrollee, physician, institution or other provider; and
  d.  The most appropriate supply or level of services which can safely be provided to the enrollee.  When applied to the care of an inpatient, it further means that services for the enrollee's medical symptoms or condition require that the services cannot be safely provided to the enrollee as an outpatient; and
  e.  When applied to enrollees under 21 years of age, services shall be provided in accordance with EPSDT requirements including federal regulations as described in 42 CFR Part 441, Subpart B, and the Omnibus Budget Reconciliation Act of 1989."  Tennessee Contract, pages 90-94.

TX

Medically necessary health care services means health care services, other than behavioral health care services which are:
 (a)  reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a handicap, cause illness or infirmity of a Member, or endanger life;
(b)  provided at appropriate facilities and at the appropriate levels of care for the treatment of a Member’s health conditions;
(c)  consistent with health care practice guidelines and standards that are endorsed by professionally recognized health care organizations or governmental agencies;
(d)  consistent with the diagnoses of the conditions; and
(e)  no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency."  Texas Contract, pages 8-9.

UT

M.  'Medically Necessary' means any medical service that (a) is reasonably calculated to prevent, diagnose, or cure conditions in the Enrollee that endanger life, cause suffering or pain, cause deformity or malfunction, or threaten to cause a handicap, and (b) there is no equally effective course of treatment available or suitable or suitable for the Enrollee requesting the service which is more conservative or substantially less costly.  Medical services will be of a quality that meets professionally recognized standards of health car, and will be substantiated by records including evidence of such medical necessity and quality.  Those records will be made available to the DEPARTMENT upon request…"  Utah Contract, Attachment B, page 2.

UTMH

Article I
DEFINITIONS...
'Medically Necessary' means any mental health service that is necessary to diagnose, correct or ameliorate a mental illness or condition, or prevent deterioration of that condition or development of additional health problems and there is no other equally effective course of treatment available or suitable that is more conservative or substantially less costly."  Utah Mental Health Contract, page 2.

"8.  Medial necessity and preferred practice guidelines - As specific guidelines are developed and accepted by mental health stakeholders to determine medical necessity and preferred practices, the CONTRACTOR agrees to operate the PMHP program in accordance with these guidelines."  Utah Mental Health Contract, page 11.

VA

ARTICLE I - DEFINITIONS...
Medical Necessity - Services sufficient in amount, duration and scope to reasonably achieve their purpose a defined in 42 C.F.R. 440.230."  Virginia Contract, page 10.

"41.  Medical Necessity
The Contractor shall cover all medically necessary services… The actual provision of any service is subject to the professional judgment of the Contractor's providers as to the medical necessity of the service, except in situations in which the contractor must provide services ordered by the Department pursuant to an appeal from the Contractor's grievance process or an appeal directly to the Department by an enrollee or for emergency services as defined in this Contract.  Decisions to provide authorized medical services required by this Contract shall be based solely on medical necessity and appropriateness.  Disputes between the Contractor and enrollees about medical necessity may be appealed to the Department by the enrollee.  The Department's determination will be based on whether Medicaid would have covered that service on a fee-for-service basis or whether the service meets the criteria for an additional service as provided under this Contract."  Virginia Contract, page 60.

WA

1.7  Medically Necessary Services means services which are reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the member requesting the service.  For the purpose of this contract, course of treatment may include mere observation or, where appropriate, no treatment at all.  Medically necessary services shall include, but not be limited to, diagnostic, therapeutic, and preventive services which are generally and customarily provided in the service area (WAC 388-500-0005.)"  Washington Contract, pages 2-3.

"4.2  Medical Necessity Determination:  The Contractor shall determine which services are medically necessary, as defined in section 1.7, according to utilization management requirements included in the Quality Improvement program standards.  The Contractor's determination of medical necessity in specific instances shall be final except as specifically provided in sections 5.2 and 5.3."  Washington Contract, page 15.

WV

2.1.1  Covered MCP Services...
Medical necessity is defined as a determination that items or services furnished or to be furnished to a patient are reasonable and necessary for the diagnosis or treatment of illness or injury, to improve the functioning of a malformed body member or for the prevention of illness…"  West Virginia RFA, page 7.

WI

The term 'medically necessary' means a medical service that meets the definition of HFS 101.03(96m) Wis. Adm. Code."  Wisconsin Contract, page 4.