Medical Necessity


Medical Necessity

One common point to discuss when processing medical insurance claims is whether the treatment is "medically necessary." In fact, all medical insurance policies require surgical or treatment expenses eligible for compensation to be "medically necessary" and within reasonable and customary charges. So what exactly is "medically necessary," and what impact does it have on claims?

“Medically necessary” refers to medical services or items that meet generally accepted medical practices or recognized medical standards, and are necessary for diagnosis and treatment. Thus, they cannot be provided to the insured person at a lower level of medical care.

Medical services usually need to meet the following conditions:

  • Require the professional knowledge or referral of a registered doctor;
  • Meet the diagnosis and treatment needs of the injury or illness;
  • Provided according to good medical standards and the professional judgment of the attending doctor;
  • Provided in an environment that is most appropriate and meets generally recognized medical standards.

Examples of Hospitalization that Meet "Medically Necessary"

Today, more and more surgeries or treatments can be performed in clinics, and the cost of the same surgery or treatment in a hospital can be much higher. Insurance companies may question whether surgery needs to be performed in a hospital, so if the insured person is considering having surgery or treatment in a hospital, they should first understand whether it meets the requirement of “medically necessary.”

Based on the policy terms of one of the major insurance companies on the market, the following are some examples of hospitalization that meet “medically necessary” for reference:

  • The surgery needs to be performed under general anesthesia
  • Hospitalization for treatment of a medical condition or illness that cannot be treated in a day-case procedure setting;
  • The attending doctor, taking into account the insured person’s personal circumstances, has made a careful professional judgment and considered the insured person’s safety, and has determined that the required medical services should be performed in a hospital.
  • After careful professional judgment by the attending doctor, the length of hospitalization is appropriate for the medical services received by the insured person.

If the medical services provided are purely for the convenience or comfort of the insured person, their caregivers, or the attending doctor, they may not necessarily meet the requirement of “medically necessary.”

Note that different insurance companies may have different interpretations of whether the medical services meet the requirement of “medically necessary.” If necessary, you should inquire with the relevant insurance company.

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