Medical policy: Medical Necessity

Número de política: MP 4.003

Fecha de entrada en vigor: 11/1/2026

Política

This policy applies if there is not a specific Medical Policy that outlines criteria for medical necessity. If a specific policy does exist, then the criteria for medical necessity in that policy may supersede the guidelines in this policy.

Specific medical policies document the circumstances and conditions under which care and services are determined to be appropriate and necessary. Capital Blue Cross defines "medical necessity or medically necessary" to mean the following:

• Services or supplies that a physician exercising prudent clinical judgment would provide to an individual for the diagnosis and/or the direct care and treatment of the individual’s medical condition, disease, illness, or injury; and
• In accordance with accepted standards of good medical practice; and
• Clinically appropriate for the individual’s medical condition, disease, illness, or injury; and
• Not primarily for the convenience of the individual and/or individual’s family, physician, or other health care provider; and
• Not costlier than alternative services or supplies at least as likely to produce equivalent results for the individual’s condition, disease, illness, or injury.

For these purposes, "generally accepted standards of good medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of physicians practicing in relevant clinical areas, and other clinically relevant factors. The fact that a provider may prescribe, recommend, order, or approve a service or supply does not of itself make it medical necessity or a covered benefit.

Exception: When a member’s contract provides benefits contrary to the medical necessity provision, Capital Blue Cross will cover services to the extent provided in the contract.

Medical necessity is established in medical policies after assessment of the scientific evidence.

La evidencia científica y otros recursos revisados incluyen, pero no se limitan a, lo siguiente:

• Decisions and recommendations of appropriate governmental regulatory bodies, such as the FDA (The Food and Drug Association), National Institutes of Health (NIH), Centers for Disease Control (CDC), Centers for Medicare and Medicaid Services (CMS), Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), and the United States Preventive Services Task Force (USPSTF)
• The opinions and evaluations of national medical organizations; professional specialty societies; clinical panels, task forces, and other technology evaluation bodies
• Available clinical evidence in published scientific literature
• External physician reviews

In addition to the Capital Blue Cross Medical Policies, Capital Blue Cross utilizes InterQual criteria, which is an industry standard set of objectives, evidence-based, utilization management criteria to assist in evaluating the medical necessity and appropriateness of medical care delivered to individuals. InterQual criteria is evaluated yearly for updates and changes.

Referencias cruzadas

• MPC-AP-12 How We Evaluate New Technology
• UM-103 Continuity of Care

Variaciones del producto

Esta política solo se aplica a ciertos programas y productos administrados por Capital Blue Cross y está sujeta a variaciones en los beneficios. Consulte la información adicional a continuación.

FEP PPO - Refer to Section VI of the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Descripción/Antecedentes

This policy describes the circumstances under which a service is considered medically necessary.

Definiciones

BlueCard Program is a program that allows the member to access covered healthcare services from Host Blue in-network providers of a Blue Cross and/or Blue Shield Licensee (Blue Plan) located outside the service area. The local Blue Plan servicing the geographic area where the covered healthcare service is provided is referred to as the “Host Blue.”

Emergency service is any healthcare services provided to a member after the onset of a medical condition, including a mental health condition or substance use disorder, that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following:

• Placing the health of the member, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
• Serious impairment to bodily functions;
• Serious dysfunction of any bodily organ or part;
• Other serious medical consequences; or
• Transportation, treatment, and related emergency services provided by a licensed emergency medical services agency if the condition is as described in this definition.

Host Blue is a local Blue Cross and/or Blue Shield Licensee serving a geographic area other than our service area that has contractual agreements with providers in that geographic area, which participate in the BlueCard program, regarding claim filing or payment for covered healthcare services rendered to our members who use services of such providers when traveling outside of our service area.

In-network provider is a professional provider, facility provider, or any other eligible healthcare provider or practitioner that is approved by Capital Blue Cross, licensed where required, provides covered services, and has entered into a provider agreement with or is otherwise engaged by Capital Blue Cross to provide benefits to the member, and who satisfies credentialing and privileging criteria. The status of a provider as an in-network provider may change from time to time. It is the member’s responsibility to verify the current status of a provider.

Out of network provider is a provider that is not under contract with Capital Blue Cross or a provider who is not a BlueCard in-network provider.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas pólizas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios de los miembros, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: esta lista de códigos puede no ser exhaustiva y los códigos están sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

Specific procedure coding does not apply to this policy.