Eligible needs will be approved for sharing when medically necessary, which is defined as healthcare services that are clinically appropriate in terms of type, frequency, extent, site, and duration for the diagnosis or treatment of the member’s sickness or injury and ordered by a Physician exercising prudent clinical judgment for the purposes of evaluation, diagnosis or treatment of that member’s sickness or injury.
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 REDEEM HealthShare’s Administrator or medical advisors.
The mere fact that the service is furnished, prescribed, or approved by a Physician does not mean that it is “Medically Necessary.”