Medically Necessary or Medical Necessity

"Medically Necessary" are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a member for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

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, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.

NOTE: For TennCare purposes, Medical Necessity and Medically Necessary are defined by Public Necessity Rules of the Tennessee Department of Finance and Administration, Bureau of TennCare, Chapter 1200-13-16 Medical Necessity.

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