Medically Necessary
For the purpose of this program, medically necessary services are those that are:
  • Intended to prevent, diagnose, correct, cure, alleviate or preclude deterioration of a diagnosable condition (ICD-9 or DSM-IV-TR) that threatens life, causes pain or suffering, or results in illness or infirmity.
  • Expected to improve an individual's condition or level of functioning.
  • Individualized, specific, and consistent with symptoms and diagnosis, and not in excess of the patient's needs.
  • Essential and consistent with nationally accepted standard clinical evidence generally recognized by mental health or substance abuse care professionals or publications.
  • Reflective of a level of service that is safe, where no equally effective, more conservative, and less costly treatment is available.
  • Not primarily intended for the convenience of the recipient, caretaker, or provider.
  • No more intensive or restrictive than necessary to balance safety, effectiveness, and efficiency.
  • Not a substitute for non-treatment services addressing environmental factors.