In health insurance, what determines if a service is covered as "medically necessary"?

In health insurance, the determination of whether a service is covered as "medically necessary" primarily relies on the insurance company guidelines for medical necessity. These guidelines are established based on various criteria, which include accepted standards of care, clinical evidence, and the necessity for services to treat, diagnose, or prevent illness. Insurers use these guidelines to ensure that they are providing coverage for services that are effective and appropriate for patients' specific health conditions.

While a healthcare provider's recommendation can influence the determination, it is ultimately the insurance company that assesses whether a service meets their criteria for coverage. This helps ensure consistency and fairness in how benefits are provided, and it allows insurers to manage costs while still providing necessary care.