Cigna's Seniors Definition of Medical Necessity for Physicians Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents. The views of physicians and health care providers practicing in relevant clinical areas.Physician and Health Care Provider Specialty Society recommendations.Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community.Cigna's Seniors Definition of Medical Necessity for other Health Care ProvidersĮxcept where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The views of physicians practicing in the relevant clinical area.Physician Specialty Society recommendations.Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community.Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or diseaseįor these purposes, "generally accepted standards of medical practice" means:. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers.Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease.In accordance with the generally accepted standards of medical practice.For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms."Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. Cigna's Definition of Medical Necessity for Physicians Health Care for Seniors Definition of Medical Necessity for other Health Care Providersįull descriptions of each are given below.Health Care for Seniors Definition of Medical Necessity for Physicians.Medical Necessity for other Health Care Providers.Cigna defines Medical Necessity in the following four ways:
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