What does "medically necessary" mean in health insurance terms?

In health insurance terminology, "medically necessary" refers to treatments or services that are essential for diagnosing or treating medical conditions. This concept is crucial because insurers use it to determine if a specific service is eligible for coverage. Medical necessity ensures that patients receive appropriate care that is justified by their health needs, balancing between effective treatment and appropriate resource utilization.

This definition emphasizes genuine health concerns, rather than patient preferences or experimental approaches. For example, if a doctor prescribes surgery to treat a severe injury, that could be deemed medically necessary, whereas a patient requesting a procedure for cosmetic reasons would not meet this criteria.

Understanding "medically necessary" helps consumers navigate insurance policies and understand the services and treatments that are typically covered by their health plans. It underscores the focus of health insurance on providing value in healthcare interventions that genuinely support patient health outcomes.