Medical Necessity And The Current Era Of Health Information Technology
The meaning of medical necessity is different for providers, physicians, courts, government/private insurers, or consumers. Medical necessity is used for managed care plans as a tool to deny or approve necessary care. From the government’s point of view, the Medicare/ Medicaid statutes authorize payment only for medically necessary care and impose criminal/civil for claims that are medically unnecessary. (Ongrod, 1999)
The United States legal doctrine defines medical necessity to activities, which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care.
From insurer’s point of view, Medicare will not cover services that are not necessary for diagnosis or treatment of illness to improve the functioning of a malformed body member. (SSA section 1862 (a) (1) (A))
As per the Medicare’s manual of claim processing, medical necessity criterion for payment in addition to the individual requirements of a CPT code. Billing a higher level of evaluation and management service is medically unnecessary or inappropriate when a lower level of service is warranted.
Medicare and private payers use…