Something that is critical to children with special health care needs receiving services from Medicaid or private insurance, including managed care plans, is the definition used to define medical necessity. Some definitions of medical necessity are too narrow and result in service denials.
The National Policy Center for Children with Special Health Care Needs published a study on this issue and developed a comprehensive approach to defining medical necessity. The study promotes a definition of medical necessity that does the following:
Any ONE of these conditions is sufficient to determine that a service or item is medically necessary. These specifications are contained in a report which can be used to promote changes to existing definitions of medical necessity where appropriate and needed.
NOTE: You can obtain a copy of the report on medical necessity by calling 1-888-434-4624 and asking for a full copy of Defining Medical Necessity Report (inventory number L071) or a copy of the executive summary (inventory number L097). There is no cost. The publication outlines the significance of medical necessity for persons with developmental disabilities, mental retardation, and other special health care needs; proposes criteria for assessing medical necessity definitions; and defines specifications for an approach to medical necessity determinations that will assure high quality of care for vulnerable populations.)
from The Family Voices Leadership Handbook
last modified: July 2000