Medical Necessity

A Medical Necessity is when the care you are seeking is appropriate and consistent with the recognized standards of treatment. Essentially, the term medical necessity relates to whether you need the service or not. If the treatment is consistent with the patient’s diagnosis, then the insurance company will pay for the treatment for that diagnosis.

Different companies have different definitions for a medical necessity, so it's vital to check your insurance documents to understand your policy’s definition.

The only benefit that doesn't generally require the medical necessity test is preventative medical care, which can be an additional benefit of some healthcare plans (Wellness).