Medically Necessary (Medical Necessity) - Services and supplies are considered medically necessary if they:
• Are essential to and consistent with the diagnosis or treatment of a specific illness or injury;
• Meet generally accepted standards of medical practice in the U.S.;
• Are not primarily for the convenience of the patient, physician, or hospital;
• Represent the most cost-efficient treatment of the condition that is safe and effective; and
• Are not experimental or investigational.The recommendation of a physician or other health care provider does not automatically make a given service or supply medically necessary.BCBSTX will determine whether a service or supply is medically necessary, considering views of the medical community, guidelines and practices of Medicare and Medicaid, and peer review literature.
Tuesday, November 27, 2007
Apropos of a discussion on Mark's blog about what sorts of perniciousness would follow from a universal (or, close to) health care plan, and in response to any notion that government sponsored health care is somehow more likely to micromanage the doctor-patient relationship, I offer this quote from my Blue Cross Blue Shield (BCBSTX) Explanation Of Benefits. The bold is in the original, the italics are mine: