CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

Definitions of medical necessity status

This document defines the insurer's meanings of 'Medically Necessary', 'Investigational', and 'Not Medically Necessary' and the criteria used to categorize services for coverage determinations. It affects providers and reviewers applying Blue Cross Blue Shield of Massachusetts policy standards.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyDefinitions of medical necessity status

Policy CodePolicy N/A

Change TypeRoutine — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionBase prior authorization decisions on whether services meet the definitions of Medically Necessary, Investigational, or Not Medically Necessary and Medical Technology Assessment Guidelines in Policy #350.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3defined terms in document

4core tests for 'Medically Necessary' (a-d)

2Not Medically Necessary reasons

Coverage Determination Criteria

Definitions used for coverage determinations

Coverage determinations follow these definitions:

Not Medically Necessary criteria: Service may be otherwise in accordance with generally accepted standards and may be clinically appropriate and effective but meets ANY of: (1) primarily for the convenience of the patient, physician, or other health care provider; AND/OR (2) more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results; services must also meet all Medical Technology Assessment Guidelines in Blue Cross Blue Shield of Massachusetts Medical Policy #350.

Non-covered

Services that do not meet the Medical Technology Assessment Guidelines in Blue Cross Blue Shield of Massachusetts Medical Policy #350 are excluded from coverage. When a service fails to satisfy those guidelines it will be classified as Investigational or Not Medically Necessary depending on whether it also fails the definitions for generally accepted standards of medical practice and clinical appropriateness.

Services that are provided primarily for convenience or that are more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results are considered Not Medically Necessary and are non‑covered. Examples include interventions chosen for the convenience of the patient, clinician, or other provider, or use of a higher‑cost option when an equivalent lower‑cost option exists.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyDefinitions of medical necessity status

Policy CodePolicy N/A

Change TypeRoutine — no material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Key Definitions

Medically Necessary — definition for coverage use

PurposeServices provided by a physician exercising prudent clinical judgment to prevent, evaluate, diagnose, or treat illness, injury, disease, or symptoms.

Key criteria (all required)a) In accordance with generally accepted standards of medical practice; b) Clinically appropriate in type, frequency, extent, site and duration and considered effective; c) Not primarily for the convenience of the patient, physician, or other health care provider; d) Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

Standards source'Generally accepted standards of medical practice' are based on credible scientific evidence in peer‑reviewed literature, relevant Physician Specialty Society recommendations, and views of physicians practicing in relevant clinical areas.

Medical Technology AssessmentServices must meet all Medical Technology Assessment Guidelines in BCBSMA Medical Policy #350.

Investigational — definition for coverage use

PurposeServices considered by a physician exercising prudent clinical judgment to prevent, evaluate, diagnose, or treat illness, injury, disease, or symptoms that fail to meet accepted standards.

Key criteria (any apply)a) Not in accordance with generally accepted standards of medical practice AND/OR b) Not clinically appropriate in type, frequency, extent, site or duration and considered effective.

Medical Technology AssessmentServices do not meet one or more Medical Technology Assessment Guidelines in BCBSMA Medical Policy #350.

Not Medically Necessary — definition for coverage use

PurposeServices that a physician may provide to prevent, evaluate, diagnose, or treat illness, injury or disease that otherwise may be appropriate but have limiting factors affecting coverage.

Primary reasons (one or both)1) Primarily for the convenience of the patient, physician, or other health care provider; AND/OR 2) More costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

Clinical appropriatenessMay be in accordance with generally accepted standards of medical practice and may be clinically appropriate and effective in type, frequency, extent, site and duration.

Medical Technology AssessmentServices must meet all Medical Technology Assessment Guidelines in BCBSMA Medical Policy #350.

Provider Responsibilities and Authorization

Prior Authorization

Prior authorization decision basis

Prior authorization decisions are made by applying the plan’s definitions of Medically Necessary, Investigational, and Not Medically Necessary. Services that meet the Medically Necessary criteria — including being consistent with generally accepted standards of medical practice, clinically appropriate in type/frequency/extent/site/duration, not primarily for convenience, and not more costly than an equivalent alternative — are candidates for approval. Services that meet the Investigational or Not Medically Necessary definitions may be denied.

Documentation Required

Documentation standards

Documentation must clearly demonstrate that the requested service meets accepted standards of care and the plan’s Medical Necessity requirements. Include clinical rationale tied to the patient’s diagnosis, prior treatments/trial outcomes, objective findings (labs, imaging, exam notes), and any relevant specialty reports. Attach copies of supporting records when submitting the authorization request.

Include objective findings (labs, imaging, exam).
Document prior conservative therapies and responses.
Attach specialty consult notes when applicable.

Note

Cost-comparison expectation

The plan expects selection of services that are no more costly than alternatives that are at least as likely to produce equivalent therapeutic or diagnostic results. When a lower‑cost, clinically equivalent option exists, authorization may be denied for a more expensive service unless the documentation justifies its medical necessity.

If an equivalent lower‑cost alternative exists, provide justification for use of the higher‑cost option.
Comparative evidence or prior trial of the less costly alternative strengthens the request.

Denial Risk

Denial risk for convenience or higher cost

Requests primarily for patient or provider convenience, or requests for services that are more costly than an alternative expected to provide equivalent results, are at higher risk for denial. Clearly document medical reasons why the requested service is required rather than elective or convenience‑driven.

Convenience (patient or provider) is not a valid basis for medical necessity.
If choosing a higher‑cost option, provide clinical justification and evidence that alternatives are unsuitable.

OpenPayer

Definitions of medical necessity status

Coverage Determination Criteria

Key Definitions

Provider Responsibilities and Authorization

Background and Purpose