Medical Necessity Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 09|05|2017 POLICY LAST REVIEWED: 02|04|2026 OVERVIEW This is an administrative policy that defines medical necessity for as adopted by Blue Cross & Blue Shield of Rhode Island (BCBSRI).
MEDICAL CRITERIA Medicare Advantage Plans According to Centers for Medicare and Medicaid Services (CMS), medically necessary services, or supplies: • Are proper and needed for the diagnosis or treatment of your medical condition. • Are provided for the diagnosis, direct care, and treatment of your medical condition. • Meet the standards of good medical practice in the local area and are not mainly for the convenience of the member or their doctor. In addition, the healthcare services provided to treat a member’s illness or injury is supported by the following: • Peer reviewed medical literature guidelines published by nationally recognized health care organizations which includes scientific data that supports the efficacy or clinical validity of the service. • The service meets professional standards of safety and effectiveness, which are generally recognized in the United States for diagnosis, care or treatment of a condition. • The opinion of health professionals in the recognized health specialty involved that supports the service. • Any other relevant information brought to our attention. According to CMS, medically necessary services or supplies: • Are proper and needed for the diagnosis or treatment of your medical condition. • Are provided for the diagnosis, direct care, and treatment of your medical condition. • Meet the standards of good medical practice in the local area and are not mainly for the convenience of you or your doctor. Commercial Products Medically necessary means that the healthcare services provided to treat a member’s illness or injury, upon review by BCBSRI are: • Appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment, or injury for which it is prescribed or performed; • Appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • Not primarily for the convenience of the member, the member’s family, or provider of such member; AND • The most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service which can safely be provided to the member, i.e., no less expensive professionally acceptable alternative is available. PRIOR AUTHORIZATION
None Medical Coverage Policy | Medical Necessity

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

POLICY STATEMENT Reimbursement is provided for all medically necessary services when the medical criteria and the guidelines noted above are met. In addition, services must be a covered benefit.

BCBSRI reserves the right to complete preauthorization or retrospective review as defined in specific medical policies. In some instances, medical records may be requested for determination of medical necessity. When medical records or clinical information is requested, all the specific information needed to make the medical necessity determination must be included.

COVERAGE Benefits may vary between groups/contracts. Please refer to Subscriber Agreement for the applicable “services not medically necessary” and out of network coverage.

BACKGROUND Not applicable

CODING Not applicable

RELATED POLICIES Out of Network Services

PUBLISHED Provider Update, April 2026 Provider Update, March 2025 Provider Update, March 2024 Provider Update, March 2023 Provider Update, April 2022

REFERENCES

1. Medicare.gov: https://www.medicare.org/articles/what-does-medically-necessary-mean/ i

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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