What is Medically Necessary treatment?

Eligible needs will be approved for sharing when medically necessary. Medically Necessary, which is defined as healthcare services that are clinically appropriate in terms of type, frequency, extent, site, and duration for the diagnosis or treatment of the member’s sickness or injury and ordered by a Physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis, or treatment of that member’s sickness or injury.

The Medically Necessary setting and level of service is that which, considering the member’s medical symptoms and conditions, cannot be provided in a less intensive medical setting. Such services, to be considered Medically Necessary, must be no more costly than alternative interventions, including no intervention, and are at least as likely to produce equivalent therapeutic or diagnostic results without adversely affecting the member’s medical condition.

• It must not be maintenance therapy or maintenance treatment;
• Its purpose must be to restore health;
• It must not be primarily custodial in nature;
• It must not be a listed item or treatment not allowed for reimbursement by CMS (Medicare); and
• Impact reserves the right to incorporate CMS (Medicare) guidelines in effect on the date of treatment as additional criteria for determination of Medical Necessity and/or eligibility of a Need.
• The mere fact that the service is furnished, prescribed or approved by a Physician does not mean that it is “Medically Necessary.”
• The determination of whether a service, supply, or treatment is or is not Medically Necessary may include findings of the American Medical Association and Impact’s own medical advisors.

Off-label Drug use is considered Medically Necessary when all of the following conditions are met:

• The Drug is approved by the FDA;
• The prescribed Drug use is supported by one of the following standard reference sources:
  • DRUGDEX;
  • The American Hospital Formulary Service Drug Information;
  • Medicare approved Compendia; or
  • Scientific evidence is supported in well-designed clinical trials published in peer-reviewed medical journals, which demonstrate that the Drug is safe and effective for the specific condition, and
  • The Drug is Medically Necessary to treat the specific condition, including life-threatening conditions or chronic and seriously debilitating conditions.