Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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Appendix C: Stanford Model Contractual Language for Medical Necessity
Appendix C: Stanford Model Contractual Language for Medical Necessity
Pages 163-164
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From page 163... ...
A health plan may choose to cover interventions that do not meet this contractual definition of medical necessity. An intervention is medically necessary if, as recommended by the treating physician1 and determined by the health plan's medical director or physician designee,2 it is all of the following: A health intervention3 for the purpose of treating a medical condition; the most appropriate supply or level of service, considering potential benefits and harms to the patient; known to be effective 4 in improving health outcomes.5 For new interventions,6 effectiveness is determined by scientific evidence.7,8 For existing interventions, 1 Treating physician means a physician who has personally evaluated the patient.
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From page 164... ...
Existing interventions can meet the contractual definition of medical necessity in the absence of scientific evidence if there is a strong conviction of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or, in the absence of such standards, convincing expert opinion. 10 An intervention is considered cost effective if the benefits and harms relative to costs represent an economically efficient use of resources for patients with this condition.
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