Medical Necessity
/ˈmɛdɪkəl nəˈsɛsɪti/
Definitions
- (n.) A legal and medical standard requiring that health care services be appropriate, reasonable, and necessary for the diagnosis or treatment of an illness or injury under accepted medical practices.
The insurance company denied the claim, arguing the treatment did not meet medical necessity.
- (n.) A criterion used by health insurers to authorize coverage based on evidence that the service is essential and effective for the patient’s health condition.
Medical necessity determinations affect whether insurers reimburse for certain procedures.
Forms
- medical necessity
Related terms
See also
Commentary
In legal drafting, medical necessity standards should be clearly defined to avoid disputes over coverage and liability.
This glossary is for general informational and educational purposes only. Definitions are jurisdiction-agnostic but reflect terminology and concepts primarily drawn from English and American legal traditions. Nothing herein constitutes legal advice or creates a lawyer-client relationship. Users should consult qualified counsel for advice on specific matters or jurisdictions.