A Patient Advocate's View

What’s Medical Necessity?

What’s the difference between medical necessity and chiropractic necessity?

According to CMS, medical necessity is a service, treatment, procedure, equipment, drug or supply provided by a hospital, physician, or other health care provider that is required to identify or treat a beneficiary’s illness or injury and which is, as determined by the contractor: a) consistent with the symptom(s) or diagnosis and treatment of the beneficiary’s illness or injury; b) appropriate under the standards of acceptable medical practice to treat that illness or injury; c) not solely for the convenience of the participant, physician, hospital, or other health care provider; and d) the most appropriate service, treatment, procedure, equipment, drug, device or supply which can be safely provided to the beneficiary and accomplishes the desired end result in the most economical manner.

According to one BCBS plan, chiropractic is a covered service when performed with the expectation of restoring the patient’s level of function which has been lost or reduced by injury or illness. Manipulations should be provided in accordance with an ongoing, written treatment plan and must be appropriate for the diagnosis reported.

From Target Coding.

November 29, 2010 - Posted by | Uncategorized

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