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What is the definition of ‘medical necessity?’

On Behalf of | Oct 3, 2016 | Insurance Disputes

Most of us do not work in the healthcare industry. We also don’t work in the health insurance industry. Therefore, when we are mere patients who receive those dreaded medical bills, it is natural that we get confused. 

Did you receive a medical bill and flinch when you saw the cost of a certain treatment? If you are like many Oklahoma residents, you probably thought a procedure was covered by insurance due to its necessity. 

The idea of “medical necessity” within the insurance industry is unfortunately more complicated than it initially sounds. 

So what does medical necessity technically mean?

According to a large health insurance provider, medically necessary treatment includes, “health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms.” 

The definition also notes how the treatment must be the standard of care according to the general industry standards. That standard includes the duration or frequency of a treatment. If there are other treatment options, the elected option must not only be proven to be reasonable and standard, but it must be comparable or lower in cost compared to other available, standard and proven options. 


When you are sick or injured and in need of medical relief, it is more than frustrating to have to try to understand insurance coverage and the cost to you and your family. Hopefully, you work with a healthcare provider whom you trust. If so, ask questions about standards of care and insurance coverage.

But even doctors can be uncertain about cost and insurance coverage. You can also talk to your insurance provider about treatment options and costs. They should be able to provide information about what treatment/procedures are covered by your plan. 

Sometimes, insurance providers are wrong. And sometimes, they act in bad faith. When that happens, an insurance lawyer can be your best advocate in order to defend your rights and your hard-earned money.