Medical necessity determination
See bold sections below:
(1) An issuer’s certificate of coverage and the summary of coverage for the health benefit plan must specifically explain any uniformly applied limitation on the scope, visit number or duration of a benefit, and state whether the uniform limitation is subject to adjustment based on the specific treatment requirements of the patient.
(2) An issuer’s medical necessity determination process must:
(a) Be clearly explained in the certificate of coverage, plan document, or contract for health benefit coverage;
(b) Be conducted fairly, and with transparency to enrollees and providers, at a minimum when an enrollee or their representative appeals or seeks review of an adverse benefit determination;
(c) Include consideration of services that are a logical next step in reasonable care if they are appropriate for the patient;
(d) Identify the information needed in the decision-making process and incorporate appropriate outcomes within a developmental framework;
(e) Ensure that when the interpretation of the medical purpose of interventions is part of the medical necessity decision making, the interpretation standard can be explained in writing to an enrollee and providers, and is broad enough to address any of the services encompassed in the ten essential health benefits categories of care;
(f) Comply with inclusion of the ten essential health benefits categories;
(g) Not discriminate based on age, present or predicted disability, expected length of life, degree of medical dependency, quality of life or other health conditions, race, gender, national origin, sexual orientation and gender identity;
(h) Include consideration of the treating provider’s clinical judgment and recommendations regarding the medical purpose of the requested service, and the extent to which the service is likely to produce incremental health benefits for the enrollee;
(i) Identify by role who will participate in the issuer’s medical necessity decision-making process; and
(j) Ensure that where medically appropriate, and consistent with the health benefit plan’s contract terms, an enrollee is not unreasonably restricted as to the site of service delivery.
(3) An issuer’s medical necessity determination process may include, but is not limited to, evaluation of the effectiveness and benefit of a service for the individual patient based on scientific evidence considerations, up-to-date and consistent professional standards of care, convincing expert opinion and a comparison to alternative interventions, including no interventions. Cost effectiveness may be one of but not the sole criteria for determining medical necessity.
(4) Within thirty days of receiving a request, an issuer must furnish its medical necessity criteria for medical/surgical benefits and mental health/substance use disorder benefits or for other essential health benefit categories to an enrollee or provider.