Provider Manual

Medical Necessity

Last Updated on February 21, 2024

Medically necessary care involves treatments, services or supplies provided by a hospital or health care provider that are required to identify or treat a member’s illness or injury and which, as determined by Security Health Plan medical directors are:

Consistent with the member’s illness or injury
In accordance with generally accepted standards of medical practice. Generally accepted standards of medical practice specifically refers to standards that are based on moderate or high-quality scientific evidence published in peer-reviewed medical literature
Not solely for the convenience of a member, hospital or other health care provider
The most appropriate level of service that can be safely provided to the member in the most cost-effective manner
Moderate or high-quality scientific evidence consists primarily of comparison or placebo-controlled clinical trials that directly demonstrate the benefit of the intervention on patient-oriented health outcomes; Non-validated surrogate or disease end point controlled or uncontrolled trials, observational trials, partially controlled observational studies and uncontrolled clinical series may be suggestive but do not, by themselves, establish sufficient strength of evidence to prove medical necessity
Psychological reactions to appearance or fear of disease do not constitute a basis for medical/surgical necessity, other than for behavioral health services
Cosmetic services or plastic surgery are not a benefit unless they represent a functional medical necessity

If there are two or more medically necessary services that may be provided for the illness, injury or medical condition, Security Health Plan will provide benefits based on the most cost-effective service. Hospital inpatient services, which include only those services that satisfy the above requirements, require the acute-bed patient (overnight) setting; and which could not have been provided in the physician’s office, the outpatient department of a hospital or in another lesser facility without adversely affecting the patient’s condition or the quality of medical care rendered. Inpatient services not medically necessary include hospitalization:

For diagnostic studies that could have been provided on an outpatient basis
For medical observation or evaluation
For personal comfort
In a pain management center to treat or cure chronic pain
For inpatient rehabilitation that can be provided on an outpatient basis

Security Health Plan reserves the right to review all claims to determine whether services are medically necessary, and may use the services of physician consultants, peer-review committees of professional societies or hospitals and other consultants. A service is not always deemed medically necessary when a health care provider has prescribed, ordered, recommended or approved a treatment, service or supply, or has informed a member of its availability.