What does "medically necessary" mean in the context of health insurance?

In the context of health insurance, "medically necessary" refers to services or supplies that are appropriate and essential for the diagnosis or treatment of a condition. This definition emphasizes that for a service to be deemed medically necessary, it must not only relate to the patient's specific health issue but also be suitable according to professional medical standards.

Coverage for medically necessary treatments is foundational to health insurance policies, as it ensures that patients receive care that genuinely addresses their health needs rather than optional services or treatments that may not be relevant to their diagnoses. Insurers typically require documentation from healthcare providers to validate that a service meets the criteria of medical necessity, which helps control costs while providing necessary care.

Understanding this concept is crucial for both patients and providers, as it affects the approval and coverage of various treatments, therapies, and interventions within a health insurance plan.