Guidelines - III.E Medically Necessary

When medically necessary, members may submit eligible bills—subject to permitted sharing levels—for sharing approval. 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, injury, or maternity and ordered by a physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis, or treatment of sickness, injury, or maternity.

The medically necessary setting and level of service must 1) be able to provide care using a less intensive medical setting and 2) match the member’s medical symptoms and conditions. For medically necessary consideration, such services must be no more costly than alternative interventions—including no intervention—and are at least as likely to produce equivalent therapeutic or diagnostic results without adversely affecting the member’s medical condition. In REDEEM Essential, REDEEM Enhanced, or REDEEM SeniorSaver, 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 III.F.
• 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 reserves the right to incorporate CMS (Medicare) guidelines in effect on the date of treatment as additional criteria for determination of medical necessity and/or eligibility of a bill.

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

The determination of whether a service, supply, or treatment is or is not medically necessary may include findings of the American Medical Association, CMS, and medical advisors for REDEEM HealthShare.

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.