Highmark Medicare Advantage Medical Policy in West Virginia

Section:	Miscellaneous
Number:	Z-11
Topic:	Definition of Medical Necessity
Effective Date:	December 21, 2009
Issued Date:	December 21, 2009

General Policy

To determine whether a service or item is denied as “not medically necessary,” and whether the limitation of liability provision is applicable:

The service or item must be otherwise covered; and,
The service or item must be determined to be not reasonable and necessary for diagnosis or treatment of any kind of illness, injury, or medical condition (investigational or experimental) or for a particular case or for certain conditions.

Indications and Limitations of Coverage

Items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered, e.g., payment cannot be made for the rental of a special hospital bed to be used by the patient in their home unless it was a reasonable and necessary part of the patient’s treatment.

Services denied as not reasonable and medically necessary, under section 1862(a)(1) of the Social Security Act, are subject to the Limitation of Liability provision. Thus, to be held liable for denied charge(s), the member must be given appropriate written advance notice of the likelihood of non-coverage and agree to pay for services. A written notice covering an extended course of treatment is acceptable, provided the notice identifies all services the provider believes will not be paid. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

A health care item or service for the purpose of causing, or assisting to cause, the death of any individual (assisted suicide) is not covered. This prohibition does not apply to the provision of an item or service for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as the item or service is not furnished for the specific purpose of causing death.

CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20

Section 1862(a)(1) of the Social Security Act - http://www.ssa.gov/OP_Home/ssact/title18/1862.htm

Services Not Reasonable and Necessary. Provider Education, Medicare Part B. NHIC, Corp. http://www.medicarenhic.com/providers/articles/srvcesnotreason_1207.pdf

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.