Medical necessity
Medical necessity is a legal doctrine in the United States related to activities that may be justified as reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. In contrast, unnecessary health care lacks such justification.
Other countries may have medical doctrines or legal rules covering broadly similar grounds. The term clinical medical necessity is also used.
Implementations of doctrine
Medicare
Medicare pays for medical items and services that are "reasonable and necessary" or "appropriate" for a variety of purposes.[1] By statute, Medicare may pay only for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member" unless there is another statutory authorization for payment.[2]
Medicare has a number of policies that describe coverage criteria, including
In a small number of cases, Medicare may determine if a method of treating a patient should be covered on a case-by-case basis. Even if a service is medically determined to be "reasonable and necessary," coverage may be limited if the service is provided more frequently than allowed under Medicare coverage policies.[note 2]
Specific instances
Medical use of marijuana
The use of
In several medical marijuana cases, the patients' physician has been willing to state to the court that the patient's condition requires this medicine and so the court should not interfere. However, the
In
See also
Notes
- ^ For more information, see the Centers for Medicare & Medicaid Services website.
- ^ For more information, see Certificate of medical necessity, MedicareLaw's "Reasonable and Necessary"[permanent dead link], or GoTelecare: Medical Billing.
References
- ^ Miller, Nancy W. (August 2002). "What is medical necessity?". Physician's News Digest. Physician's News Digest, Inc. Archived from the original on 2012-04-18. Retrieved 4 January 2020.
- ^ "Sec. 1862. [42 U.S.C. § 1395y]: EXCLUSIONS FROM COVERAGE AND MEDICARE AS SECONDARY PAYER", The Social Security Laws, United States Social Security Administration,
Sec. 1862. [42 U.S.C. 1395y] (a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services— (1)(A) which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,....
- ^ "Medicare LCDs and NCDs in Medical Coding and Billing". Dummies. John Wiley & Sons, Inc. Retrieved 4 January 2020.
- ^ "Becoming a Patient in Maryland". Americans for Safe Access. Retrieved 4 January 2020.
External links
- Your Medicare Coverage from medicare.gov
- Medicare Coverage Database which includes NCDs, LMRP/LCDs, as well as NCAs & CALs, from cms.hhs.gov
- Physician Fee Schedule lookup at cms.hhs.gov
- Defining Medical Necessity Under the Patient Protection and Affordable Care Act at academia.edu, by Daniel R. Skinner, published in the journal Public Administration Review (2013).
- Medical Necessity: Health Care Access and the Politics of Decision Making by Daniel Skinner, a book published by the University of Minnesota Press (2019).
- Charles Martin, "Medical Use of Cannabis in Australia: 'Medical necessity' defences under current Australian law and avenues for reform" (2014) 21(4) Journal of Law and Medicine 875.
- Florida's Medical Necessity Defense, Reconsidered by Miami attorney Jared H. Beck