• Health care services or products … for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms (AMA, 2005; Harmon, 2011; Maves, 2010)

• Health care … for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms (Kaminiski, 2007)

• “Medically necessary” is a term for describing a requested service that is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent worsening of conditions in the client that endanger life, cause suffering or pain, result in an illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other equally effective, more conservative, or substantially less costly course of treatment available or suitable for the client requesting the service. For the purpose of this section, “course of treatment” may include mere observation or, where appropriate, no treatment at all (Washington Administrative Code, 2011)

• To prevent the onset or worsening of an illness, condition, or disability; to establish a diagnosis; to provide palliative, curative, or restorative treatment for physical and/or mental health conditions; and/or to 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 (Dhillon, 2011; NHeLP, 2011)

• To acquire, retain, and improve the self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings (Medicaid per [Ford, 2011])

• Screening and diagnostic services to determine physical or mental defects in recipients under age 21; and health care, treatment, and other measures to correct or ameliorate any defects and chronic conditions discovered1

• For the diagnosis, cure, mitigation, treatment, or prevention of disease or for the purpose of affecting any structure or function of the body2

• 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 occurring3

• For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member4

• Necessary to prevent, diagnose, correct, or cure 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 handicap5

Scope

• Clinically appropriate in terms of type, frequency, extent, site, and duration (AMA, 2005)

• Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient’s illness, injury, or disease (Kaminiski, 2007)

• The most appropriate supply or level of service, considering potential benefits and harms to the patient (Singer et al., 1999)

Evidence

• In accordance with generally accepted standards of medical practice (AMA, 2005; Harmon, 2011)

• In accordance with generally accepted standards of medical practice; this means standards that are based on credible scientific evidence published in peer-reviewed medical literature, generally recognized by the

1 Code of Federal Regulations, Title 42, Chapter IV, § 440.40(current as of August 3, 2011).

2 Internal Revenue Tax Code, Title 26, Subtitle A, Chapter 1 § 213(d)(1)(A).

3 Connecticut Agency Regulations, § 17b-134d-63, et seq.

4 Social Security Act, 42 U.S.C. Title XVIII, Section 1862(a)(1)(a).

5 New York State Social Services Law, Title 1, Article 5, § 365 (a).



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