Preferred Option
Medically Necessary means services and supplies which under the terms of the applicable Service Agreement are “Medically Necessary”.  No service is a Covered Service unless it is Medically Necessary.  Hospital represents and     Payer stipulates that each medical staff member has the requisite training and education to make all decisions related to patient care and shall exercise independent medical judgment with respect to all such matters. Payer shall not     interfere with any medical staff member’s independent medical judgment with regard to treatment or utilization issues. Any payment or absence of payment for services shall not constitute an opinion or affirmation by Payer that the     services or procedures recommended or rendered by a member of medical staff are, are not, were or were not medically appropriate, but only that the service or procedure was not a Plan benefit.

“Medically Necessary” or “Medical Necessity” means, unless otherwise defined in the applicable Plan, that the Covered Services provided by a Participating Facility to diagnose or treat an illness or condition meet all of the following criteria: a. the service is appropriate for the symptoms, diagnosis, and treatment of a particular disease or condition that is defined under ICD-9-CM or DSM-IV, or its replacement; b. the service is provided in accordance with locally accepted standards of behavioral healthcare professional practice; c. the service is not rendered primarily for the convenience of the patient, the patient’s family, the Participating Facility, or any other person; and d. the type, level, and length of treatment services are needed to provide safe and adequate care.