Rule 5160-1-01 | Medicaid medical necessity: definitions and principles.
(A) Medical necessity for individuals covered by early and periodic screening, diagnosis and treatment (EPSDT) is criteria of coverage for 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 criteria of coverage for 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 for a procedure, item, or service are met if all the following apply:
(1) It meets generally accepted standards of medical practice;
(2) It is clinically appropriate in its type, frequency, extent, duration, and delivery setting;
(3) It is appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome;
(4) It is the lowest cost alternative that effectively addresses and treats the medical problem;
(5) It provides unique, essential, and appropriate information if it is used for diagnostic purposes; and
(6) It is not provided primarily for the economic benefit of the provider nor for the sole 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.
(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 the Ohio department of medicaid (ODM) coverage policies or rules.
Last updated February 24, 2022 at 8:25 AM
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