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State Definitions of Medical Necessity under the Medicaid EPSDT Benefit

State Medicaid programs are required to provide Medicaid enrollees under age 21 with comprehensive and preventive health care services through the Early Screening and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. EPSDT services include but are not limited to:

  • comprehensive health and developmental history screenings,
  • health education,
  • laboratory tests, vision services,
  • dental services, and
  • hearing services.

Services for children are covered under the EPSDT benefit if the services are deemed medically necessary for the individual beneficiary. Federal law requires states to cover, under the EPSDT benefit, “necessary health care, diagnostic services, treatment, and other measures’ to correct or ameliorate defects along with physical and mental illnesses and other conditions discovered by the screening services, whether or not such services are covered under the State plan.”

Child Health Services under the Medicaid EPSDT Benefit

Medicaid is a critical program for children and youth with special health care needs (CYSHCN). CYSHCN are defined as children who have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services beyond that required by children generally. CYSHCN account for nearly 20 percent (13.8 million) of children under the age of 18. Nearly 50 percent of CYSHCN in the United States are covered by state Medicaid and CHIP programs. In addition to primary care and screening services, EPSDT also covers specialty services important to CYSHCN including:

  • rehabilitative and habilitative therapies
  • long term services and supports such as private duty nursing and attendant care,
  • assistive technology, and
  • non-emergency medical transportation to essential medical and social services.

State Medical Necessity Definitions for EPSDT

Federal law requires states to cover, under the EPSDT benefit, services “whether or not such services are covered under the State plan.” The federal statute does not define “medical necessity” but rather describes a broad standard for coverage without providing a prescriptive formula for ascertaining necessity. States can establish their own parameters for medical necessity decisions so long as those parameters are not more restrictive than the federal statute. In March 2021, NASHP conducted a 50-state scan of medical necessity definitions used by state Medicaid programs for their EPSDT benefit, updating a previous scan conducted in 2013. All states define medical necessity in their Medicaid program, as compared to 42 states and the District of Columbia in 2013. In general, states define medically necessary services as those that: improve health or lessen the impact of a condition, prevent a condition, or restore health.

 

State Medical Necessity Definition for EPSDT Services 
Alabama ** 

Alabama’s Medicaid Provider Manual defines medical necessity as: any health care service, intervention, or supply (collectively referred to as “service”) that a physician (or psychologist, when applicable), exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, [including mental illnesses and substance use disorders], injury, disease, condition, or its symptoms, in a manner that is:  

  • in accordance with generally accepted standards of medical practice; • clinically appropriate in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury, disease, or condition;  
  • in accordance with medical necessity “guidelines/references” in Agency’s Administrative Code, State Plan, and Provider Manual;  
  • not primarily for the convenience of the patient or Provider;  
  • not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, disease, or condition.  
  • the service is not contraindicated; and • the Provider’s records include sufficient documentation to justify the service. For these purposes, “generally accepted standards of medical practice” means: • Standards that are based on credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community are required when applicable; or  
  • Alternatively, may consider physician specialty society recommendations [clinical treatment guidelines/guidance] and/or the general consensus of physicians practicing in relevant clinical areas.  

Application of medical necessity is unique with regard to Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit/services. All full benefit eligible Medicaid enrollees under age twenty-one (21) may receive EPSDT benefit/services in accordance with sections 1905(a) and 1905(r) of the Social Security Act. Included are services identified as a result of a comprehensive screening visit or an inter-periodic screening, regardless of whether or not they are ordinarily covered for all other Medicaid Enrollees. Additionally, all services necessary to correct or ameliorate a physical or mental illness or condition are included.  

The fact that a Provider has prescribed, recommended, or approved services does not, in itself, make such services medically necessary, a medical necessity, or a Covered Service. At Agency’s request, the Provider must submit the written documentation to comply with “generally accepted standards of medical practice” as defined within the medical necessity definition. Experimental and cosmetic procedures are only allowed in limited circumstances as outlined in Agency’s Administrative, Code Chapter 6, Rule No. 560-X-6-.13 Covered Services: Details on Selected Services.  

State Administrative code 560-x-11-.14  defines medical necessity for EPSDT services as follows: The state requires that Medicaid covers medically necessary services identified in a child’s EPSDT screening whether or not such services are covered in the State Plan. If services are not originally provided as a Medicaid benefit, providers of the service will be enrolled to provide “EPSDT only” referred care. A provider must maintain an EPSDT referral form for services provided as result of a screening. All Medicaid services are subject to retrospective review for medical necessity.  

Alaska ** 

Medical necessity for EPSDT services is defined under Alaska Admin. Code 110.210 

(a)The department will pay for a service recommended as a result of the EPSDT screening, if that service is an authorized service under 42 U.S.C. 1396- 1396w-1. 

(b) The department will pay for the following additional services for children under 21 years of age if the screening identifies a need for that service: 

(1) podiatry services under 7 AAC 110.500 - 7 AAC 110.505; 

(2) nutrition services under 7 AAC 110.275; 

(3) private-duty nursing services under 7 AAC 110.520 - 7 AAC 110.535; 

(4) hospice care under 7 AAC 140.280; 

(5) chiropractic services under 7 AAC 110.120; 

(6) dental services under 7 AAC 110.140 - 7 AAC 110.160; 

(7) physical therapy under 7 AAC 115.300 - 7 AAC 115.320; 

(8) occupational therapy under 7 AAC 115.100 - 7 AAC 115.120; 

(9) speech therapy under 7 AAC 115.400 - 7 AAC 115.420; 

(10) autism services under 7 AAC 135.350 

Arizona 

 

Arizona State Administrative Code in Section 9.A.A.C. 22 defines “Medically necessary” services as a covered service is provided by a physician or other licensed practitioner of the healing arts within the scope of practice under state law to prevent disease, disability, or other adverse health conditions or their progression, or to prolong life. 

Specific definitions for EPSDT services are found in the Medical Policy for MCH Manual: 

EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in Federal Law 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan.  

Arkansas ** 

Arkansas’ Medicaid Provider Manual defines medical necessity as:  

A service is “medically necessary” if it is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or injury, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction and if there is no other equally effective (although more conservative or less costly) course of treatment available or suitable for the beneficiary requesting the service.   

For this purpose, a “course of treatment” may include mere observation or (where appropriate) no treatment at all.   

The determination of medical necessity may be made by the Medical Director for the Medicaid Program or by the Medicaid Program Quality Improvement Organization (QIO).  Coverage may be denied if a service is not medically necessary in accordance with the preceding criteria or is generally regarded by the medical profession as experimental, inappropriate, or ineffective using unless objective clinical evidence demonstrates circumstances making the service necessary. 

California  California Welfare and Institutions Codesection 14059.5, subd. (b), defines medically necessary services for individuals under 21 years of age as those services that meet the standards set forth in Section 1396d(r)(5) of Title 42 of The United States Code. Accordingly, a service is considered “medically necessary” or a “medical necessity” if it corrects or ameliorates defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State Plan. 
Colorado ** 

Medical necessity as defined in Colorado Code of Regulations 8.076.1.8 means a Medical Assistance program good or service:  

a. Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all;  

b. Is provided in accordance with generally accepted professional standards for health care in the United States;  

c. Is clinically appropriate in terms of type, frequency, extent, site, and duration;  

d. Is not primarily for the economic benefit of the provider or primarily for the convenience of the client, caretaker, or provider;  

e. Is delivered in the most appropriate setting(s) required by the client’s condition;  

f. Is not experimental or investigational; and  

g. Is not more costly than other equally effective treatment options.  

Medical necessity for EPSDT services is defined under 8.282.4.E 

For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b – g. 

Connecticut 

 

“Medically Necessary” has the same meaning as provided in section 17b-259b of the Connecticut General Statutes: 

For purposes of the administration of the medical assistance programs by the Department of Social Services, “medically necessary” and “medical necessity” mean those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual’s medical condition, including mental illness, or its effects, in order to attain or maintain the individual’s achievable health and independent functioning provided such services are:  

(1) Consistent with generally-accepted standards of medical practice that are defined as standards that are based on  

(A) credible scientific evidence published in peer-reviewed medical literature that is generally recognized by the relevant medical community,  

(B) recommendations of a physician-specialty society,  

(C) the views of physicians practicing in relevant clinical areas, and  

(D) any other relevant factors;  

(2) clinically appropriate in terms of type, frequency, timing, site, extent and duration and considered effective for the individual’s illness, injury or disease;  

(3) not primarily for the convenience of the individual, the individual’s health care provider or other health care providers;  

(4) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual’s illness, injury or disease; and  

(5) based on an assessment of the individual and his or her medical condition. 

Delaware 

 

The Delaware Medicaid and Medical Assistance program’s definition of Medical Necessity can be found in the General Policy Manual on the DMAP Provider Portal. 

Medical Necessity is defined as: 

The essential need for health care or services (all covered State Medicaid Plan services, subject to age and eligibility restrictions and/or EPSDT requirements) which, when delivered by or through authorized and qualified providers, will: 

  • Be directly related to the prevention, diagnosis, and treatment of a member’s disease, condition, and/or disorder that results in health impairments and/or disability (the physical or mental functional deficits that characterize the member’s condition), and be provided to the member only.   
  • Be appropriate and effective to the comprehensive profile (e.g. needs, aptitudes, abilities, and environment) of the member and the member’s family.   
  • Be primarily directed to treat the diagnosed medical condition or the effects of the condition on the member, in all settings for normal activities of daily living.   
  • Be timely, considering the nature and current state of the member’s diagnosed condition and its effects, and will be expected to achieve the intended outcomes in a reasonable time.   
  • Be the least costly, appropriate, available health service alternative, and will represent an effective and appropriate use of program funds.   
  • Be the most appropriate care or service that can be safely and effectively provided to the member, and will not duplicate other services provided to the member.   
  • Be sufficient in amount, scope and duration to reasonably achieve its purpose.   
  • Be recognized as either the treatment of choice (i.e. General Policy Provider Policy Manual prevailing community or statewide standard) or common medical practice by the practitioner’s peer group, or the functional equivalent of other care and services that are commonly provided.   
  • Be rendered in response to a life threatening condition or pain, or to treat an injury, illness, or other diagnosed condition, or to treat the effects of a diagnosed condition that has resulted in or could result in a physical or mental limitation, including loss of physical or mental functionality or developmental delay.   

In order that   

  • The member might attain or retain independence, selfcare, dignity, self-determination, personal safety, and integration into all natural family, community, and facility environments and activities.  

District of Columbia 

 

The District of Columbia defines Medical Necessity in its Managed Care Contract: 

C.5.30.7 Medically Necessary Services  

C.5.30.7.1 A service is Medically Necessary if a physician or other treating health Provider, exercising prudent clinical judgment, would provide or order the service for an Enrollee for the purpose of evaluating, diagnosing or treating illness, injury, disease, physical or mental health conditions, or their symptoms, and the provision of the service is in compliance with 1905(a) of the Act, 42 U.S.C. § 1396d(a), to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State Plan. Medically Necessary services shall be:  

C.5.30.7.1.1 No more restrictive than those used in the Medicaid program, including quantitative and non-quantitative treatment limits, as indicated in District statutes and regulations, the State Plan, and other District policy and procedures;  

C.5.30.7.2 Services and benefits that promote normal growth and development and prevent, diagnose, detect, treat, ameliorate the effects or a physical, mental, behavioral, genetic, or congenital condition, injury, or disability for Enrollees under age twenty-one (21); 

C.5.30.7.3 Provided in accordance with generally accepted standards of medical practice;  

C.5.30.7.4 Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Enrollee’s illness, injury, disease, or physical or mental health condition;  

C.5.30.7.5 Not primarily for the convenience of the Enrollee or treating physician, or other treating healthcare Providers, and more cost effective than an alternative service or sequence of services, and at least as likely to produce equivalent therapeutic or diagnostic results with respect to the diagnosis or treatment of that Enrollees illness, injury, disease or physical or mental health condition; and  

C.5.30.7.6 Specific to the Enrollee and shall take into account available clinical evidence, as well as recommendations of the treating clinician and other clinical, educational, and social services professionals who treat or interact with the Enrollee. 

Florida ** 

The Florida Medicaid definitions manual defines Medically Necessary as: 

The medical or allied care, goods, or services furnished or ordered must meet the following conditions:  

  • Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain  
  • Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs  
  • Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational  
  • Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide  
  • Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider  

The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.  

Medically necessary or medical necessity for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type. 

Florida Statutes 409.9131 further define medical necessity as: means any goods or services necessary to palliate the effects of a terminal condition or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity, which goods or services are provided in accordance with generally accepted standards of medical practice. For purposes of determining Medicaid reimbursement, the agency is the final arbiter of medical necessity. In making determinations of medical necessity, the agency must, to the maximum extent possible, use a physician in active practice, either employed by or under contract with the agency, of the same specialty or subspecialty as the physician under review. Such determination must be based upon the information available at the time the goods or services were provided. 

Georgia 

 

Georgia Code 49-4-169.1 defines medical necessity services for children: 

 (1) ”Correct or ameliorate” means to improve or maintain a child’s health in the best condition possible, compensate for a health problem, prevent it from worsening, prevent the development of additional health problems, or improve or maintain a child’s overall health, even if treatment or services will not cure the recipient’s overall health. 

(2) ”Department” means the Department of Community Health. 

(3) ”EPSDT Program” means the federal Medicaid Early Periodic Screening, Diagnostic, and Treatment Program contained at 42 U.S.C.A. Sections 1396a and 1396d. 

(4) ”Medically necessary services” means services or treatments that are prescribed by a physician or other licensed practitioner, and which, pursuant to the EPSDT Program, diagnose or correct or ameliorate defects, physical and mental illnesses, and health conditions, whether or not such services are in the state plan. 

Hawaii 

 

Hawaii Administrative Rules §17-1700.1-2  

defines medical necessity as follows: 

 “Medical necessity” means those procedures and services, as determined by the department, which are considered to be necessary and for which payment will be made. Medically necessary health interventions (services, procedures, drugs, supplies, and equipment) must be used for a medical condition. There shall be sufficient evidence to draw conclusions about the intervention’s effects on health outcomes. The evidence shall demonstrate that the intervention can be expected to produce its intended effects on health outcomes. The intervention’s beneficial effects on health outcomes shall outweigh its expected harmful effects. The intervention shall be the most cost effective method available to address the medical condition. Sufficient evidence is provided when evidence is sufficient to draw conclusions, if it is peer-reviewed, is well-controlled, directly or indirectly relates the intervention to health outcomes, and is reproducible both within and outside of research settings. 

Idaho ** 

Idaho statute 41-5903 (31) defines medically necessary services: “medical necessity” means the definition provided in the covered person’s health benefit plan; if the covered person’s health benefit plan does not define “medically necessary” or “medical necessity,” these terms shall mean health care services and supplies that a physician or other health care provider, exercising prudent clinical judgment, would provide to a covered person for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: 

(a)  In accordance with generally accepted standards of medical practice; 

(b)  Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the covered person’s illness, injury or disease; 

(c)  Not primarily for the convenience of the covered person, physician or other health care provider; and 

(d)  Not more costly than an alternative service or sequence of services or supply, and at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the covered person’s illness, injury or disease. 

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible medical or scientific evidence. 

Idaho Admin Code 16.03.09.880 defines Medically necessary services for eligible Medicaid participants under the age of twenty-one (21): as health care, diagnostic services, treatment, and other measures described in Section 1905(a) of the Social Security Act (SSA) necessary to correct or ameliorate defects, physical and mental illness, and conditions discovered by the screening services as defined in Section 1905(r) of the SSA, whether or not such services are covered under the State Plan. Services must be considered safe, effective, and meet acceptable standards of medical practice.  

Illinois 

 

 Section 140.485 of the Healthy Kids Program defines medical necessity for the EPSDT program: 

The Department shall pay for necessary medical care (see Section 140.2), diagnostic services, treatment or other measures medically necessary (e.g., medical equipment and supplies) to correct or ameliorate defects, and physical and mental illnesses and conditions which are discovered or determined to have increased in severity by medical, vision, hearing or dental screening services. 

Section 140.2: “Necessary medical care” is that which is generally recognized as standard medical care required because of disease, disability, infirmity or impairment. 

Indiana ** 

Indiana Admin. Code 405 5-2-17 defines medically necessary service as covered services (as defined in section 6 of this rule) that is required for the care or well-being of the patient and is provided in accordance with generally accepted standards of medical or professional practice. For a service to be reimbursable by the office, it must: 

(1) be medically necessary, as determined by the office, which shall, in making that determination, utilize generally accepted standards of medical or professional practice; and 

(2) not be listed in this title as a noncovered service, or otherwise excluded from coverage. 

Iowa 

 

Iowa Rule 441—73.1(249A) defines “medically necessary services” as those covered services that are, under the terms and conditions of the contract, determined through contractor utilization management to be: 

1. Appropriate and necessary for the symptoms, diagnosis or treatment of the condition of the member;  

2. Provided for the diagnosis or direct care and treatment of the condition of the member to enable the member to make reasonable progress in treatment;  

3. Within standards of professional practice and given at the appropriate time and in the appropriate setting; 

4. Not primarily for the convenience of the member, the member’s physician or other provider; and  

5. The most appropriate level of covered services that can safely be provided 

Kansas ** 

KanCare defines medical necessity refers to a health intervention that meets the following guidelines:  

1. it is recommended by the treating physician or other appropriate licensed medical professional.  

2. it has the purpose of treating a medical condition.  

3. it provides the most appropriate supply or level of service, considering potential harms and benefits to the patient.  

4. it is known to be effective in improving health outcomes.  

5. it is cost-effective for the condition being treated when compared to alternative interventions. 

Kentucky ** 

Kentucky Code 907 3:130 defines medically necessary services:  

(1) The determination of whether a covered benefit or service is medically necessary shall: 

(a) Be based on an individualized assessment of the recipient’s medical needs; and 

(b) Comply with the requirements established in this paragraph. To be medically necessary or a medical necessity, a covered benefit shall be: 

1. Reasonable and required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition, including pregnancy; 

2. Appropriate in terms of the service, amount, scope, and duration based on generally-accepted standards of good medical practice; 

3. Provided for medical reasons rather than primarily for the convenience of the individual, the individual’s caregiver, or the health care provider, or for cosmetic reasons; 

4. Provided in the most appropriate location, with regard to generally-accepted standards of good medical practice, where the service may, for practical purposes, be safely and effectively provided; 

5. Needed, if used in reference to an emergency medical service, to exist using the prudent layperson standard; 

6. Provided in accordance with early and periodic screening, diagnosis, and treatment (EPSDT) requirements established in 42 U.S.C. 1396d(r) and 42 C.F.R. Part 441 Subpart B for individuals under twenty-one (21) years of age; and 

7. Provided in accordance with 42 C.F.R. 440.230. 

The department shall have the final authority to determine the medical necessity and clinical appropriateness of a covered benefit or service and shall ensure the right of a recipient to appeal a negative action in accordance with 907 KAR 1:563. 

Louisiana ** 

Louisiana State Regulation 1101 defines medically necessary services: 

A. Medically necessary services are defined as those health care services that are in accordance with generally accepted evidence-based medical standards or that are considered by most physicians (or other independent licensed practitioners) within the community of their respective professional organizations to be the standard of care. 

B. In order to be considered medically necessary, services must be: 

1. deemed reasonably necessary to diagnose, correct, cure, alleviate or prevent the worsening of a condition or conditions that endanger life, cause suffering or pain or have resulted or will result in a handicap, physical deformity or malfunction; and 

2. those for which no equally effective, more conservative and less costly course of treatment is available or suitable for the recipient. 

C. Any such services must be individualized, specific and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and neither more nor less than what the recipient requires at that specific point in time. 

D. Although a service may be deemed medically necessary, it doesn’t mean the service will be covered under the Medicaid Program. Services that are experimental, non-FDA approved, investigational or cosmetic are specifically excluded from Medicaid coverage and will be deemed “not medically necessary.” 

1. The Medicaid director, in consultation with the Medicaid medical director, may consider authorizing services at his discretion on a case-by-case basis. 

Maine ** 

The MaineCare Benefits Manual defines Medical Necessity or Medically Necessary services as those reasonably necessary medical and remedial services that are: 

1.Provided in an appropriate setting; 

2. Recognized as standard medical care, based on national standards for best practices and safe, effective, quality care; 

3. Required for the diagnosis, prevention and/or treatment of illness, disability, infirmity or impairment and which are necessary to improve, restore or maintain health and well-being; 

4. MaineCare covered services (subject to age, eligibility, and coverage restrictions as specified in other Sections of this manual as well as Early and Periodic Screening, Diagnosis and Treatment Services requirements as detailed in Chapter II, Section 94 of this Manual); 

5. Performed by enrolled providers within their scope of licensure and/or certification; and 

6. Provided within the regulations of this Manual. 

Maryland 

 

The Maryland Medical Assistance Program Provider Manual defines “medical necessary” services as those that are 

  • Directly related to diagnostic, preventative, curative, palliative, rehabilitative or ameliorative treatment of an illness, injury, disability or health condition;  
  • Consistent with current accepted standards of good medical practice;  
  • The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and  
  • Not primarily for the convenience of the consumer, their family or the provider. 
Massachusetts ** 

Massachusetts Regulatory Code 450.204 defines medical necessity: 

(A) A service is medically necessary if 

(1) it is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in illness or infirmity; and 

(2) there is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to the MassHealth agency. Services that are less costly to the MassHealth agency include, but are not limited to, health care reasonably known by the provider, or identified by the MassHealth agency pursuant to a prior-authorization request, to be available to the member through sources described in 130 CMR 450.317 

(C), 503.007: Potential Sources of Health Care, or 517.007: Utilization of Potential Benefits. 

(B) Medically necessary services must be of a quality that meets professionally recognized standards of health care, and must be substantiated by records including evidence of such medical necessity and quality. A provider must make those records, including medical records, available to the MassHealth agency upon request. (See42 U.S.C. 1396a(a)(30) and 42 CFR 440.230 and 440.260.) 

(C) A provider’s opinion or clinical determination that a service is not medically necessary does not constitute an action by the MassHealth agency. 

(D) Additional requirements about the medical necessity of MassHealth services are contained in other MassHealth regulations and medical necessity and coverage guidelines. 

(E) Any regulatory or contractual exclusion from payment of experimental or unproven services refers to any service for which there is insufficient authoritative evidence that such service is reasonably calculated to have the effect described in 130 CMR 450.204(A)(1). 

Michigan 

 

Michigan recognizes the AAP definition of “medical necessity” as: Health care interventions that are evidence based, evidence informed, or based on consensus advisory opinion and that are recommended by recognized health care professionals to promote optimal growth and development in a child and to prevent, detect, diagnose, treat, ameliorate, or palliate the effects of physical, genetic, congenital, developmental, behavioral, or mental conditions, injuries, or disabilities. 

Minnesota 

 

Minnesota Administrative Rule 9505.0175 defines a medically necessary service as  

A health service that is consistent with the recipient’s diagnosis or condition and: 

A.is recognized as the prevailing standard or current practice by the provider’s peer group; and 

B. is rendered in response to a life-threatening condition or pain; or to treat an injury, illness, or infection; or to treat a condition that could result in physical or mental disability; or to care for the mother and child through the maternity period; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition; or 

C. is a preventive health service under part 9505.0355. 

Mississippi 

 

Mississippi’s Administrative Code, Refer to [Part 200, Rule 5.1], defines “medically necessary or “medical necessity” as health care services that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:  

1. Appropriate and consistent with the diagnosis of the treating provider and the omission of which could adversely affect the patient’s medical condition,  

2. Compatible with the standards of acceptable medical practice in the United States,  

3. Provided in a safe, appropriate and cost-effective setting given the nature of the diagnosis and the severity of the symptoms,  

4. Not provided solely for the convenience of the beneficiary or family, or the convenience of any health care provider,  

5. Not primarily custodial care,  

6. There is no other effective and more conservative or substantially less costly treatment service and setting available, and  

7. The service is not experimental, investigational or cosmetic in nature. 

Mississippi’s Administrative Code, Refer to [Part 223, Rule 1.7], the Division of Medicaid covers any medically necessary Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) diagnostic and treatment services required to correct or ameliorate physical, mental, psychosocial, and/or behavioral health conditions discovered by a screening, whether or not such services are covered under any Medicaid Administrative Rule or the State Plan for EPSDT-eligible beneficiaries and, if required, prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity. 

Missouri ** 

Missouri’s Provider handbook defines medical necessity: 

Service(s) furnished or proposed to be furnished that is (are) reasonable and medically necessary for the prevention, diagnosis, or treatment of a physical or mental illness or injury; to achieve age appropriate growth and development; to minimize the progression of a disability; or to attain, maintain, or regain functional capacity; in accordance with accepted standards of practice in the medical community of the area in which the physical or mental health services are rendered; and service(s) could not have been omitted without adversely affecting the participant’s condition or the quality of medical care rendered; and service(s) is(are) furnished in the most appropriate setting. Services must be sufficient in amount, duration, and scope to reasonably achieve their purpose and may only be limited by medical necessity, and aren’t mainly for the convenience of you or your doctor.  

Missouri’s administration rules on EPSDT echo the federal definition of medical necessity for children, stating that “Medical and dental services which Section 1905(a) of the Social Security Act permits to be covered under MO HealthNet and which are necessary to treat or ameliorate defects, physical, and mental illness or conditions identified by an EPSDT screen are covered regardless of whether or not the services are covered under the Medicaid state plan. 

Montana ** 

Montana Rule ARM 37.82.102 (18) defines a “Medically necessary service” as a service or item reimbursable under the Montana Medicaid program, as provided in these rules:  

(a) Which is reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions in a patient which:  

(i) endanger life;  

(ii) cause suffering or pain; 

(iii) result in illness or infirmity;  

(iv) threaten to cause or aggravate a handicap; or (v) cause physical deformity or malfunction.  

(b) A service or item is not medically necessary if there is another service or item for the recipient that is equally safe and effective and substantially less costly including, when appropriate, no treatment at all.  

(c) Experimental services or services which are generally regarded by the medical profession as unacceptable treatment are not medically necessary for purposes of the Montana Medicaid program.  

(i) Experimental services are procedures and items, including prescribed drugs, considered experimental or investigational by the U.S. Department of Health and Human Services, including the Medicare program, or the department’s designated review organization or procedures and items approved by the U.S. Department of Health and Human Services for use only in controlled studies to determine the effectiveness of such services. 

Nebraska 

 

Nebraska DHHS defines medical necessity as: 

Services and supplies which do not meet the definition of medical necessity are not covered. For purposes of Medicaid fee-for-service and  

Managed Care, medical necessity is health care services and supplies which are medically appropriate and:  

(i.) Necessary to meet the basic health needs of the client;  

(ii.) Rendered in the most cost-efficient manner;  

(iii.) Rendered in a type of setting appropriate for the delivery of the covered service;  

(iv.) Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;  

(v.) Consistent with the diagnosis of the condition;  

(vi.) Required for means other than convenience of the client or the physician;  

(vii.) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; and  

(viii.) Relative to the goal of improved patient health outcomes 

Nevada ** 

 

Nevada’s Medicaid Services Manual defines medical necessity as: 

“A health care service or product that is provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to: diagnose, treat or prevent illness or disease; regain functional capacity; or reduce or ameliorate effects of an illness, injury or disability. 

The determination of medical necessity is made on the basis of the individual case and takes into account: 

  • Type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies. 
  • Level of service that can be safely and effectively furnished, and for which no equally effective and more conservative or less costly treatment is available. 
  • Services are delivered in the setting that is clinically appropriate to the specific physical and mental/behavioral health care needs of the recipient. 
  • Services are provided for medical or mental/behavioral reasons rather than for the convenience of the recipient, the recipient’s caregiver, or the health care provider.” 

Medical Necessity shall take into account the ability of the service to allow recipients to remain in a community based setting, when such a setting is safe, and there is no less costly, more conservative or more effective setting.  

New Hampshire 

 

New Hampshire Regulations define medical necessary services as follows: 

  1.  For any eligible member:  health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are:

     a. Clinically appropriate in extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms; 

    b.  Not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider; 

    c.  No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient’s illness, injury, disease, or its symptoms; and 

    d. Not experimental, investigative, cosmetic, or duplicative in nature. 

  2. For any eligible member under age 21 in addition to the above, reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the EPSDT recipient requesting a medically necessary service. 

The fact that a Provider has prescribed, recommended, or approved services does not, in itself, make such services medically necessary, a medical necessity, or a Covered Service. 

New Jersey 

 

New Jersey State Regulations defines medical necessity as follows: 

“Medically necessary services” means services or supplies necessary to prevent, diagnose, correct, prevent the worsening of, alleviate, ameliorate, or cure a physical or mental illness or condition; to maintain health; to prevent the onset of an illness, condition, or disability; to prevent or treat a condition that endangers life or causes suffering or pain or results in illness or infirmity; to prevent the deterioration of a condition; to promote the development or maintenance of maximal functioning capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate to individuals of the same age; to prevent or treat a condition that threatens to cause or aggravate a handicap or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the enrollee. The services provided, as well as the treatment, the type of provider and the setting, are reflective of the level of services that can be safely provided, are consistent with the diagnosis of the condition and appropriate to the specific medical needs of the enrollee and not solely for the convenience of the enrollee or provider of service and in accordance with standards of good medical practice and generally recognized by the medical scientific community as effective. Course of treatment may include mere observation or, where appropriate, no treatment at all. Experimental services or services generally regarded by the medical profession as unacceptable treatment are deemed not medically necessary. Medically necessary services provided are based on peer-reviewed publications, expert pediatric, psychiatric, and medical opinion, and medical/pediatric community acceptance. In the case of pediatric enrollees, this definition applies, with the additional criteria that the services, including those found to be needed by a child as a result of a comprehensive screening visit or an inter-periodic encounter, whether or not they are ordinarily covered services for all other Medicaid/NJ FamilyCare enrollees, are appropriate for the age and health status of the individual and that the service will aid the overall physical and mental growth and development of the individual and the service will assist in achieving or maintaining functional capacity. 

New Mexico ** 

New Mexico Code 8.302.1.7  defines medically necessary services as services that: 

                    (1)     are essential to prevent, diagnose or treat medical conditions or are essential to enable an eligible recipient to attain, maintain or regain functional capacity; 

                    (2)     are delivered in the amount, duration, scope and setting that is clinically appropriate to the specific physical and behavioral health care needs of the eligible recipient; 

                    (3)     are provided within professionally accepted standards of practice and national guidelines; and 

                    (4)     are required to meet the physical and behavioral health needs of the eligible recipient and are not primarily for the convenience of the eligible recipient, the provider or the payer. 

B. Application of the definition: (4)     Decisions regarding MAD benefit coverage for eligible recipients under 21 years of age shall be governed by the early periodic screening, diagnosis and treatment (EPSDT) coverage rules. 

New York ** New York state law defines Medically Necessary Service as health care and services that are necessary to prevent, diagnose, manage or treat 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 handicap 

North Carolina ** 

 

North Carolina EPSDT policies define medical necessity as:
services include any medical or remedial care that is medically necessary to correct or ameliorate a defect, physical or mental illness, or condition [health problem].  This means that EPSDT covers most of the treatments a recipient under 21 years of age needs to stay as healthy as possible, and North Carolina Medicaid must provide for arranging for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment the need for which is disclosed by such child health screening services. “Ameliorate” means to improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Even if the service will not cure the recipient’s condition, it must be covered if the service is medically necessary to improve or maintain the recipient’s overall health.  

North Dakota  

 

North Dakota state law defines “Medically necessary” to include only medical or remedial services or supplies required for treatment of illness, injury, diseased condition, or impairment; consistent with the recipient’s diagnosis or symptoms; appropriate according to generally accepted standards of medical practice; not provided only as a convenience to the recipient or provider; not investigational, experimental, or unproven; clinically appropriate in terms of scope, duration, intensity, and site; and provided at the most appropriate level of service that is safe and effective. 

Ohio ** 

 

Ohio State Code 5160-1-01 defines medical necessity as follows:  

(A) Medical necessity for individuals covered by early and periodic screening, diagnosis and treatment (EPSDT) is defined as procedures, items, or services that prevent, diagnose, evaluate, correct, ameliorate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability. 

(B) Medical necessity for individuals not covered by EPSDT is defined as procedures, items, or services that prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without which the person can be expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort. 

(C) Conditions of medical necessity are met if all the following apply: 

(1) Meets generally accepted standards of medical practice; 

(2) Clinically appropriate in its type, frequency, extent, duration, and delivery setting; 

(3) Appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome; 

(4) Is the lowest cost alternative that effectively addresses and treats the medical problem; 

(5) Provides unique, essential, and appropriate information if it is used for diagnostic purposes; and 

(6) Not provided primarily for the economic benefit of the provider nor for the convenience of the provider or anyone else other than the recipient. 

Oklahoma ** 

 

Oklahoma Rule 317:30-3-1 defines medical necessity as follows: 

Services provided within the scope of the Oklahoma Medicaid Program shall meet medical necessity criteria. Requests by medical services providers for services in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority shall serve as the final authority pertaining to all determinations of medical necessity. Medical necessity is established through consideration of the following standards:
(1) Services must be medical in nature and must be consistent with accepted health care practice standards and guidelines for the prevention, diagnosis or treatment of symptoms of illness, disease or disability; 

(2) Documentation submitted in order to request services or substantiate previously provided services must demonstrate through adequate objective medical records, evidence sufficient to justify the client’s need for the service; 

(3) Treatment of the client’s condition, disease or injury must be based on reasonable and predictable health outcomes; 

(4) Services must be necessary to alleviate a medical condition and must be required for reasons other than convenience for the client, family, or medical provider; 

(5) Services must be delivered in the most cost-effective manner and most appropriate setting; and 

(6) Services must be appropriate for the client’s age and health status and developed for the client to achieve, maintain or promote functional capacity. 

Oregon 

 

Oregon State Rules define  

“Medically Appropriate” means health services, items, or medical supplies that are:  

(a) Recommended by a licensed health provider practicing within the scope of their license;  

(b) Safe, effective, and appropriate for the patient based on standards of good health practice and generally recognized by the relevant scientific or professional community based on the best available evidence;  

(c) Not solely for the convenience or preference of an OHP client, member, or a provider of the service item or medical supply; and  

(d) The most cost effective of the alternative levels or types of health services, items, or medical supplies that are covered services that can be safely and effectively provided to a Division client or member in the Division or MCE’s judgment; 

(e) All covered services must be medically appropriate for the member or client but not all medically appropriate services are covered services. 

 

“Medically Necessary” as health services and items that are required by a client or member to address one or more of the following: 

(a) The prevention, diagnosis, or treatment of a client or member’s disease, condition, or disorder that results in health impairments or a disability; 

(b) The ability for a client or member to achieve age-appropriate growth and development; 

(c) The ability for a client or member to attain, maintain, or regain independence in self-care, ability to perform activities of daily living or improve health status; or 

(d) The opportunity for a client or member receiving Long Term Services & Supports (LTSS) as defined in these rules to have access to the benefits of non-institutionalized community living, to achieve person centered care goals, and to live and work in the setting of their choice; 

(e) A medically necessary service must also be medically appropriate. All covered services must be medically necessary but not all medically necessary services are covered services. 

Pennsylvania 

 

Pennsylvania Code 1101.21a defines “medical necessity” as: 

A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that: 

   (1)  Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability. 

   (2)  Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. 

   (3)  Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age. 

Rhode Island ** 

 

Rhode Island’s Provider Manual defines “medical necessity” or “medically necessary service” as medical, surgical, or other services required for the prevention, diagnosis, cure or treatment of a health related condition including such services necessary to prevent a decremental change in either medical or mental health status. Medically necessary services must be provided in the most cost effective and appropriate setting and shall not be provided solely for the convenience of the beneficiary, caretaker, or service provider. 

South Carolina 

 

Medically necessary” means that the service (the provision of which may be limited by specific provisions, bulletins, and other directives) is directed toward the maintenance, improvement, or protection of health or toward the diagnosis and treatment of illness or disability.” 

Further, EPSDT policy: All coverable, medically necessary, services must be provided even if the service is not available under Healthy Connections Medicaid to beneficiaries through the month of their 21st birthday. Additional health care services are available under the federal Medicaid program if they are medically necessary to treat, correct or ameliorate illnesses and conditions discovered regardless of whether the service is covered by the State Plan. 

Healthy Connections Medicaid makes the final determination of medical necessity and it is determined on a case-by-case basis. Provider recommendations will be taken in to consideration, but are not the sole determining factor in coverage. Healthy Connections Medicaid determines which treatment it will cover among equally effective, available alternative treatments. All in-state resources should be exhausted before treatment outside of the state is considered. 

South Dakota ** 

 

The South Dakota Medicaid Billing and Policy Manual defines a medically necessary service as: 

  • It is consistent with the recipient’s symptoms, diagnosis, condition, or injury;  
  • It is recognized as the prevailing standard and is consistent with generally accepted professional medical standards of the provider’s peer group;  
  • It is provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition; • It is not furnished primarily for the convenience of the recipient or the provider; and  
  • There is no other equally effective course of treatment available or suitable for the recipient requesting the service that is more conservative or substantially less costly 

Tennessee 

 

Tennessee Code 71-5-144 defines Medical Necessity as follows: (b) To be determined to be medically necessary, a medical item or service must be recommended by a physician who is treating the enrollee or other licensed healthcare provider practicing within the scope of the physician’s license who is treating the enrollee and must satisfy each of the following criteria: 

(1) It must be required in order to diagnose or treat an enrollee’s medical condition. The convenience of an enrollee, the enrollee’s family, or a provider, shall not be a factor or justification in determining that a medical item or service is medically necessary; 

(2) It must be safe and effective. To qualify as safe and effective, the type and level of medical item or service must be consistent with the symptoms or diagnosis and treatment of the particular medical condition, and the reasonably anticipated medical benefits of the item or service must outweigh the reasonably anticipated medical risks based on the enrollee’s condition and scientifically supported evidence; 

(3) It must be the least costly alternative course of diagnosis or treatment that is adequate for the medical condition of the enrollee. When applied to medical items or services delivered in an inpatient setting, it further means that the medical item or service cannot be safely provided for the same or lesser cost to the person in an outpatient setting. Where there are less costly alternative courses of diagnosis or treatment, including less costly alternative settings, that are adequate for the medical condition of the enrollee, more costly alternative courses of diagnosis or treatment are not medically necessary. An alternative course of diagnosis or treatment may include observation, lifestyle or behavioral changes or, where appropriate, no treatment at all; and 

(4) 

(A) It must not be experimental or investigational. A medical item or service is experimental or investigational if there is inadequate empirically-based objective clinical scientific evidence of its safety and effectiveness for the particular use in question. This standard is not satisfied by a provider’s subjective clinical judgment on the safety and effectiveness of a medical item or service or by a reasonable medical or clinical hypothesis based on an extrapolation from use in another setting or from use in diagnosing or treating another condition; 

(B) Use of a drug or biological product that has not been approved under a new drug application for marketing by the United States Food and Drug Administration (FDA) is deemed experimental; 

(C) Use of a drug or biological product that has been approved for marketing by the FDA but is proposed to be used for other than the FDA-approved purpose will not be deemed medically necessary unless the use can be shown to be widespread, to be generally accepted by the professional medical community as an effective and proven treatment in the setting and for the condition for which it is used, and to satisfy the requirements of subdivisions (b)(1)-(3). 

(c) It is the responsibility of the bureau of TennCare ultimately to determine what medical items and services are medically necessary for the TennCare program. The fact that a provider has prescribed, recommended or approved a medical item or service does not, in itself, make such item or service medically necessary. 

(d) The medical necessity standard set forth in this section shall govern the delivery of all services and items to all enrollees or classes of beneficiaries in the TennCare program. The bureau of TennCare is authorized to make limited special provisions for particular items or services, such as long-term care, or such as may be required for compliance with federal law. 

(e) Medical protocols developed using evidence-based medicine that are authorized by the bureau of TennCare pursuant to § 71-5-107 shall satisfy the standard of medical necessity. Such protocols shall be appropriately published to all TennCare providers and managed care organizations. 

(f) The bureau of TennCare is authorized to promulgate such rules and regulations as may be necessary to implement this section. 

Texas 

 

The Texas Administrative Code provides a general definition of medically necessary services under EPSDT, known in Texas as Texas Health Steps (THSteps).   

Medically necessary–Medical services that are supported by documentation which show the services are: 

    (A) reasonable and necessary to prevent illness, medical or dental conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a client, or endanger life; 

    (B) consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental agencies; 

    (C) consistent with the diagnoses of the conditions; 

    (D) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; 

    (E) not experimental or investigative; and 

    (F) not primarily for the convenience of the client or provider. 

Certain THSteps services may have more specific definitions of medically necessary.  All THSteps services must be medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions.  

Utah ** 

 

The Utah Medicaid Provider Manual defines a medically necessary service as it is reasonably calculated to prevent, diagnose, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, or threaten to cause a disability, and there is no other equally effective course of treatment available or suitable for the member requesting the service which is more conservative or substantially less costly. Medical services will be of a quality that meets professionally recognized standards of health care and will be substantiated by records including evidence of such medical necessity and quality. Those records will be made available to the Medicaid upon request. Medicaid reserves the right to make the final determination of medical necessity. Services or procedures considered experimental or investigational are not considered medically necessary and thus are not covered by Medicaid. 

Vermont 

 

Vermont Health Care Administrative Rules define medically necessary services under the EPSDT benefit as follows:   

Medically necessary” means health care services, including diagnostic testing, preventive services, and aftercare, that are appropriate, in terms of type, amount, frequency, level, setting, and duration, to the beneficiary’s diagnosis or health condition, and that:  

(1) help restore or maintain the beneficiary’s health, or
(2) prevent deterioration or palliate the beneficiary’s condition, and
(3) are the least costly, appropriate health service that is available, and
(4) are not solely for the convenience of the beneficiary’s caregiver or a provider, and (5) are supported by documentation in the beneficiary’s medical records.  

Virginia ** 

 

Virginia’s Medicaid Provider Manual defines “medically necessary services” as those services that are covered under the State Plan and are reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member. Coverage may be denied if the requested service is not medically necessary according to the preceding criteria or is generally regarded by the medical profession as experimental or unacceptable.  

EPSDT Specialized Services are medically necessary treatment services that are not a routinely covered service through Virginia Medicaid. All EPSDT “specialized services” must be a service that is allowed by the Centers for Medicare and Medicaid Services (CMS). The allowable treatment services are defined in the United States Code in 42 U.S.C. sec 1396d (r) (5) 

Washington 

 

Medical necessity is defined in the Washington Administrative Code (WAC 182-500-0070) as: 

“a term for describing requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent worsening of conditions in the client that endanger life, or cause suffering or pain, or result in an illness or infirmity, or 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 purposes of this section, ‘course of treatment’ may include mere observation or, where appropriate, no medical treatment at all.” 

West Virginia ** 

 

The West Virginia Provider Manual defines medical necessity as “items or services furnished to a patient that are reasonable and necessary for the diagnosis or treatment of illness or injury, to improve the functioning of a malformed body member, to attain, maintain, or regain functional capacity, for the prevention of illness, or to achieve age appropriate growth and development.   

Wisconsin ** 

 

Under Wisconsin Administrative Code DHS 101.03(96m)medical necessity is defined as a medical assistance service under ch. DHS 107 that is:  

(a) Required to prevent, identify or treat a recipient’s illness, injury or disability; and 

(b) Meets the following standards: 

1. Is consistent with the recipient’s symptoms or with prevention, diagnosis or treatment of the recipient’s illness, injury or disability; 

2. Is provided consistent with standards of acceptable quality of care applicable to the type of service, the type of provider and the setting in which the service is provided; 

3. Is appropriate with regard to generally accepted standards of medical practice; 

4. Is not medically contraindicated with regard to the recipient’s diagnoses, the recipient’s symptoms or other medically necessary services being provided to the recipient; 

5. Is of proven medical value or usefulness and, consistent with s. DHS 107.035, is not experimental in nature; 

6. Is not duplicative with respect to other services being provided to the recipient; 

7. Is not solely for the convenience of the recipient, the recipient’s family or a provider; 

8. With respect to prior authorization of a service and to other prospective coverage determinations made by the department, is cost-effective compared to an alternative medically necessary service which is reasonably accessible to the recipient; and 

9. Is the most appropriate supply or level of service that can safely and effectively be provided to the recipient. 

Wyoming  

 

Wyoming Medicaid Rules defines “medical necessity” for the Health Check program as: 

A determination that a health service is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected to relieve pain or to improve and preserve health and be essential to life. The service must be: 

(A) Consistent with the diagnosis and treatment of the client’s condition;  

(B) In accordance with the standards of good medical practice among the provider’s peer group;  

(C) Required to meet the medical needs of the client and undertaken for reasons other than the convenience of the client and the provider;  

(D) Performed in the most cost effective and appropriate setting required by the client’s condition.  

This work was supported by The Catalyst Center.

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