5160-1-01 Medicaid medical necessity: definitions and principles.

Medical necessity is a fundamental concept underlying the medicaid program.

(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.

(D) The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment for it.

(E) The definition and conditions of medical necessity articulated in this rule apply throughout the entire medicaid program. More specific criteria regarding the conditions of medical necessity for particular categories of service may be set forth within ODM coverage policies or rules.

Replaces: 5160-1-01

Effective: 3/22/2015
Five Year Review (FYR) Dates: 03/22/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/1/80, 2/19/82, 10/1/84, 10/1/87, 6/1/91, 5/30/02, 07/01/2006