A covered service or item is medically necessary if it will do, or is reasonably expected to do one or more of the following:

• Arrive at a correct medical diagnosis¹

• Prevent the onset of an illness, condition, injury, or disability (in the individual or in covered relatives, as appropriate)²

• Reduce, correct, or ameliorate the physical, mental, developmental, or behavioral effects of an illness, condition, injury, or disability

• Assist the individual to achieve or maintain sufficient functional capacity to perform age-appropriate or developmentally appropriate daily activities

The MCO or insurer must determine medical necessity on the basis of health information provided by the following persons: the individual (as appropriate to his or her age and communicative abilities), the individual's family, the primary care physician, and consultants with appropriate specialty training, as well as other providers, programs, multidisciplinary teams, educational institutions, or agencies that have evaluated the individual.

The determination of medical necessity must be made on an individual basis and must consider

• The functional capacity of the person and those capacities that are appropriate for persons of the same age or developmental level

• Available research findings, health care practice guidelines, and standards issued by professionally recognized organizations or government agencies

Final determination will be made by a physician in concert with the following persons: the individual's primary care physician; a consultant with experience appropriate to the individual's age, disability, or chronic condition; and the individual and/or family.

Medically necessary services must be delivered in a setting (e.g., an individual's home, school, child-care center, workplace, or community-based agency) that is appropriate to the specific health needs of the individual.

¹Unspecified or undiagnosed conditions are common in this population: hence, additional or special diagnostic procedures or tests are frequently needed to reach a diagnosis that will assist in determining an appropriate care plan.

²Knowledge about the role of genetics in chronic disease and disability is growing rapidly. For example, diagnosis of fragile X syndrome in a child requires pedigree analysis and laboratory studies not only permit accurate diagnosis, but also to ensure that genetic counseling is provided to help individuals and families make informed choices on reproductive issues.

Taken from IREYS, HT, WEHR, E., COOKE, RE, 1999 Defining Medical Necessity: Strategies for Promoting Access to Quality Care for Persons with Developmental Disabilities, Mental Retardation, and Other Special Health Care Needs. National Center for Education in Maternal and Child Health.

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