Medical policy: Medical Necessity

Policy number: MP 4.003

Effective date: 11/1/2026

Policy

This policy applies if there is not a specific Medical Policy that outlines criteria for medical necessity. If a specific policy does exist, then the criteria for medical necessity in that policy may supersede the guidelines in this policy.

Specific medical policies document the circumstances and conditions under which care and services are determined to be appropriate and necessary. Capital Blue Cross defines “medical necessity or medically necessary” to mean the following:

• Services or supplies that a physician exercising prudent clinical judgment would provide to an individual for the diagnosis and/or the direct care and treatment of the individual’s medical condition, disease, illness, or injury; and
• In accordance with accepted standards of good medical practice; and
• Clinically appropriate for the individual’s medical condition, disease, illness, or injury; and
• Not primarily for the convenience of the individual and/or individual’s family, physician, or other health care provider; and
• Not costlier than alternative services or supplies at least as likely to produce equivalent results for the individual’s condition, disease, illness, or injury.

For these purposes, “generally accepted standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations and the views of physicians practicing in relevant clinical areas, and other clinically relevant factors. The fact that a provider may prescribe, recommend, order, or approve a service or supply does not of itself make it medical necessity or a covered benefit.

Exception: When a member’s contract provides benefits contrary to the medical necessity provision, Capital Blue Cross will cover services to the extent provided in the contract.

Medical necessity is established in medical policies after assessment of the scientific evidence.

Scientific evidence and other resources reviewed include, but are not limited to:

• Decisions and recommendations of appropriate governmental regulatory bodies, such as the FDA (The Food and Drug Association), National Institutes of Health (NIH), Centers for Disease Control (CDC), Centers for Medicare and Medicaid Services (CMS), Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), and the United States Preventive Services Task Force (USPSTF)
• The opinions and evaluations of national medical organizations; professional specialty societies; clinical panels, task forces, and other technology evaluation bodies
• Available clinical evidence in published scientific literature
• External physician reviews

In addition to the Capital Blue Cross Medical Policies, Capital Blue Cross utilizes InterQual criteria, which is an industry standard set of objectives, evidence-based, utilization management criteria to assist in evaluating the medical necessity and appropriateness of medical care delivered to individuals. InterQual criteria is evaluated yearly for updates and changes.

Cross-references

• MPC-AP-12 How We Evaluate New Technology
• UM-103 Continuity of Care

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to Section VI of the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Description/Background

This policy describes the circumstances under which a service is considered medically necessary.

Definitions

BlueCard Program is a program that allows the member to access covered healthcare services from Host Blue in-network providers of a Blue Cross and/or Blue Shield Licensee (Blue Plan) located outside the service area. The local Blue Plan servicing the geographic area where the covered healthcare service is provided is referred to as the “Host Blue.”

Emergency service is any healthcare services provided to a member after the onset of a medical condition, including a mental health condition or substance use disorder, that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following:

• Placing the health of the member, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
• Serious impairment to bodily functions;
• Serious dysfunction of any bodily organ or part;
• Other serious medical consequences; or
• Transportation, treatment, and related emergency services provided by a licensed emergency medical services agency if the condition is as described in this definition.

Host Blue is a local Blue Cross and/or Blue Shield Licensee serving a geographic area other than our service area that has contractual agreements with providers in that geographic area, which participate in the BlueCard program, regarding claim filing or payment for covered healthcare services rendered to our members who use services of such providers when traveling outside of our service area.

In-network provider is a professional provider, facility provider, or any other eligible healthcare provider or practitioner that is approved by Capital Blue Cross, licensed where required, provides covered services, and has entered into a provider agreement with or is otherwise engaged by Capital Blue Cross to provide benefits to the member, and who satisfies credentialing and privileging criteria. The status of a provider as an in-network provider may change from time to time. It is the member’s responsibility to verify the current status of a provider.

Out of network provider is a provider that is not under contract with Capital Blue Cross or a provider who is not a BlueCard in-network provider.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These polices are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Specific procedure coding does not apply to this policy.