Guidelines - 3.9 Medically Necessary

You may submit eligible bills for sharing approval when they are 
medically necessary and meet the permitted sharing levels.

3.9.1.     Definition of Medically Necessary.

Medically necessary refers to health care services that are 
clinically appropriate in terms of type, frequency, extent, site, and 
duration for the diagnosis or treatment of sickness, or injury. 

3.9.2.     Qualified Medical Professionals.

A qualified, licensed medical professional must use prudent 
clinical judgment and must have one of the designations listed 
in section 3.6 Approved Sharing of Bills to order services or 
treatments for the purposes of evaluation, diagnosis, or treatment 
of sickness or injury. 

3.9.3. Criteria for Medically Necessary Services. 
The setting and level of service must 1) be able to provide care 
that is unavailable using a less intensive medical setting and 2) 
match your medical symptoms and conditions. Services must not 
cost more than other treatment options, including doing nothing, 
that work as well without harming your health. The medically 
necessary service must meet all the following requirements:

• Its purpose must be to restore health.

• It must be eligible for reimbursement in the United States by 
CMS (Medicare) or listed in section 3.10 Limited Sharing.

• It must be eligible for sharing per the program Guidelines.

• It must not be maintenance therapy or maintenance treatment.

• It must not be primarily custodial in nature.

REDEEM HealthShare considers CMS (Medicare) guidelines in effect 
on the date of treatment, along with findings from the AMA, CMS, 
and its medical advisors, when determining medical necessity and 
bill eligibility.

Even though a provider delivered, prescribed, or approved service 
does not mean that it is medically necessary.

3.9.4. Off-label Drugs. 

REDEEM HealthShare considers sharing of off-label drug use 
medically necessary when the off-label drug meets the following 
conditions:

• FDA approval.

• One of the following standard reference sources supports the 
prescribed drug’s use:

- DRUGDEX.

- The American Hospital Formulary Service Drug Information.

- Medicare-approved compendia.

Scientific evidence must come from well-designed clinical trials
published in peer-reviewed medical journals. These studies must 
demonstrate that the drug is safe and effective for the specific
condition. The drug is medically necessary to treat the specific 
condition, including life-threatening conditions or chronic and 
seriously debilitating conditions