Medical Necessity
Definition of Medical Necessity for Physicians
“Medically Necessary” or “Medical Necessity” means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:
- For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
- In accordance with the generally accepted standards of medical practice
- Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient’s illness, injury, or disease
- Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
- 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 disease
For these purposes, “generally accepted standards of medical practice” means:
- Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
- Physician Specialty Society recommendations
- The views of physicians practicing in the relevant clinical area
- Any other relevant factors
Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.
Resource: https://www.healthcare.gov/glossary/medically-necessary/
* Please be aware that New York State Law (Educational Law and Regents Rules) requires that you have a medical evaluation (yearly physical) as a part of your care, particularly if you are have been medically diagnosed with schizophrenia, schizo-affective disorder, bi-polar, major depression disorder, panic disorder, obsessive-compulsive disorder, attention-deficit hyperactivity disorder, or autism.
Our services are available to anyone with any diagnosis but you will have to be engaged in services with another provider if you meet medical necessity. We are earnest about our understanding on what is developmental trauma, normative dissociation, and universal addictions and see how these are not currently diagnosable. We are supporting stress reduction, posttraumatic growth, recovery healing, resiliency training, healing maintenance, and performance enhancement.
For more information about our take on it: HERE