CIGNA - Medical Necessity Definitions

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Medical Necessity Definitions

		CIGNA HealthCare Definition of Medical Necessity for Physicians
		CIGNA HealthCare Definition of Medical Necessity for other Healthcare Providers
		CIGNA HealthCare for Seniors Definition of Medical Necessity for Physicians
		CIGNA HealthCare for Seniors Definition of Medical Necessity for other Healthcare Providers

CIGNA HealthCare Definition of Medical Necessity for Physicians

“Medically Necessary” or “Medical Necessity” shall mean health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

a)		in accordance with the generally accepted standards of medical practice;
b)		clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
c)		not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means:

		standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community;
		Physician Specialty Society recommendations;
		the views of Physicians practicing in the relevant clinical area; and
		any other relevant factors.

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

CIGNA HealthCare Definition of Medical Necessity for other Healthcare Providers

Except where state law or regulation requires a different definition, “Medically Necessary” or “Medical Necessity” shall mean health care services that a Healthcare Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

a)		in accordance with the generally accepted standards of medical practice;
b)		clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
c)		not primarily for the convenience of the patient or Healthcare Provider, a Physician or any other Healthcare Provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means:

		standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community,
		Physician and Healthcare Provider Specialty Society recommendations,
		the views of Physicians and Healthcare Providers practicing in relevant clinical areas and
		any other relevant factors.

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

CIGNA HealthCare for Seniors Definition of Medical Necessity for Physicians

a)		in accordance with the generally accepted standards of medical practice;
b)		clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
c)		not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means:

		standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community;
		Physician Specialty Society recommendations;
		the views of Physicians practicing in the relevant clinical area; and
		any other relevant factors.

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the Evidence of Coverage booklet.

CIGNA HealthCare for Seniors Definition of Medical Necessity for other Healthcare Providers

a)		in accordance with the generally accepted standards of medical practice;
b)		clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
c)		not primarily for the convenience of the patient or Healthcare Provider, a Physician or any other Healthcare Provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

For these purposes, “generally accepted standards of medical practice” means:

		standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community,
		Physician and Healthcare Provider Specialty Society recommendations,
		the views of Physicians and Healthcare Providers practicing in relevant clinical areas and
		any other relevant factors.

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.