Medical Supplies or Supplies: supplies which are medically necessary disposable items, primarily serving a medical purpose, (and generally not useful to a person in the absence of illness, injury, or disease) having therapeutic or diagnostic characteristics essential in enabling a participant to effectively carry out a physician’s prescribed treatment for illness, injury, or disease, and are appropriate for use in the participant’s home.
Medically Necessary: A service or supply furnished by a particular provider is medically necessary if it is determined by the Plan that it is appropriate for the diagnosis, the care, or the treatment of the disease or injury involved. To be appropriate, the service or supply must: Be care or treatment, as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person’s overall health condition; Be a diagnostic procedure, indicated by the health status of the person and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person’s overall health condition; and As to diagnosis, care and treatment be no more costly (taking into account all health expense incurred in connection with the service or supply) than any alternative service or supply to meet the above tests.
In determining if a service or supply is appropriate under the circumstances, the following will be taken into consideration: Information provided on the affected person’s health status; Reports in peer reviewed medical literature; Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; Generally recognized professional standards of safety and effectiveness in the United States for diagnosis, care, or treatment; The opinion of health professionals in the generally recognized health specialty involved; and, Any other relevant information.
In no event will the following services or supplies be considered to be medically necessary: Those that do not require the technical skills of a medical, a mental health, or a dental professional; or Those furnished mainly for the personal comfort or convenience of the person, any person who cares for him or her, any person who is part of his or her family, any healthcare provider, or healthcare facility; or Those furnished solely because the person is an inpatient on any day on which the person’s disease or injury could safely and adequately be diagnosed or treated while not confined; or Those furnished solely because of the setting if the service or supply could safely and adequately be furnished in a physician’s office or other less costly setting.
Medically necessary services or supplies must be: Prescribed by a physician to be necessary and appropriate; Non-experimental or non-investigational; Not in conflict with accepted medical or surgical practices prevailing in the geographic area where, and at the time when, the service or supply is ordered;