CurrentUniversity Health Alliance (HSA)Policy MPP-0102-130701

Medical Necessity Determination (Coverage Criteria)

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Defines UHA's medical necessity criteria, decision-making process, applicable standards of evidence, and administrative guidelines for coverage determinations affecting health care services and products for UHA members.

Policy Summary

PayerUniversity Health Alliance (HSA)

PolicyMedical Necessity Determination (Coverage Criteria)

Policy CodePolicy MPP-0102-130701

Change TypeNo material changes

Effective DateAug 10, 2021

Last ReviewAug 10, 2021

Next Review Date

Key ActionProviders may request reconsideration and peer-to-peer clinical review when coverage is denied for medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

HRS §432E-1.4Statutory definition used

All non-admin benefitsScope breadth

CMO/Medical DirectorFinal decision makers

Hierarchy definedEvidence precedence

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CurrentUniversity Health Alliance (HSA)Policy MPP-0102-130701

Medical Necessity Determination (Coverage Criteria)

Customize your policy alerts

Sign up for University Health Alliance (HSA) Policy MPP-0102-130701 alerts

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Policy Summary

PayerUniversity Health Alliance (HSA)

PolicyMedical Necessity Determination (Coverage Criteria)

Policy CodePolicy MPP-0102-130701

Change TypeNo material changes

Effective DateAug 10, 2021

Last ReviewAug 10, 2021

Next Review Date

Key ActionProviders may request reconsideration and peer-to-peer clinical review when coverage is denied for medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

HRS §432E-1.4Statutory definition used

All non-admin benefitsScope breadth

CMO/Medical DirectorFinal decision makers

Hierarchy definedEvidence precedence

Coverage and Medical Necessity Criteria

Medical necessity core criteria

Covered when ALL of the following are met (per UHA and Hawaii statute):

Statutory/practice criteria: Service is an otherwise covered category, not specifically excluded, recommended by the treating licensed provider, and determined by the plan's medical director to be medically necessary.

based on HRS §432E-1.4 subsec (a)

Purpose: For the purpose of treating a medical condition (prevent, diagnose, treat, maintain or restore functional ability).

HRS definition of treat/medical condition

Appropriateness: The most appropriate delivery or level of service considering potential benefits and harms to the patient (type, frequency, extent, site, duration).

UHA criteria for clinical appropriateness

Effectiveness: Known to be effective in improving health outcomes, with effectiveness determined first by scientific evidence; if no scientific evidence then professional standards of care; if none or contradictory then expert opinion.

Evidence hierarchy per statute and policy

Cost-effectiveness: Cost-effective for the medical condition compared to alternatives, where cost-effective does not necessarily mean lowest price and individual patient characteristics are determinative.

HRS cost-effectiveness clause

Services that are specifically excluded by the member's benefit plan or contract are not covered even if they otherwise meet criteria for medical necessity. UHA follows the benefit contract language and the exclusions listed therein when making coverage determinations; an item or service expressly excluded in the member's policy will not be paid regardless of clinical justification.

When UHA has sufficient evidence showing a treatment is not medically necessary in the usual case, coverage may be denied. In such situations the burden is on the patient and the treating provider to demonstrate that the individual case differs from the usual presentation and that the treatment is medically necessary for that individual. Documentation supplied by the provider should specifically address why the patient is an exception to the usual case.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization and appeal

Certain services identified by UHA payment policies may require prior authorization; when coverage is denied for medical necessity providers may request reconsideration and a peer‑to‑peer clinical review through the UHA appeals process.

Prior authorization required as indicated by UHA payment policies.
Providers may request reconsideration and peer‑to‑peer clinical review after a medical necessity denial.

Note

Request reconsideration and peer review

Treating providers may submit clinical documentation to request that UHA reconsider a denial and to open a dialog with UHA's Chief Medical Officer or Medical Director when determinations may be modified by additional medical evidence.

Provider may provide additional clinical evidence to modify a decision.
UHA will facilitate expeditious handling of physician requests for peer‑to‑peer clinical reviews and appeals.

Policy Background and Standards

UHA applies a prudent physician standard and gives precedence to scientific evidence when determining medical necessity. Where controlled clinical evidence is available, it guides determinations of effectiveness and appropriateness; if scientific evidence is lacking, UHA relies on professional standards of care, and when those are absent or conflicting, expert clinical opinion may be considered. Medical necessity decisions consider the appropriateness of type, frequency, extent, site, duration, and the relative cost-effectiveness of alternatives, and final determinations rest with the CMO/Medical Director and clinical leadership.

Key Definitions

inv-09: Health intervention — definition and scope

TermHealth intervention

DefinitionAn item or service delivered or undertaken primarily to treat a medical condition or to maintain or restore functional ability; defined by the intervention plus the medical condition and patient indications for which it is applied.

ScopeApplies to new interventions (evaluated by professional standards or expert opinion if clinical trials absent) and existing interventions (scientific evidence considered first).

Relation to outcomesEvaluated in context of intended effect on health outcomes for the specified condition and patient indications.

Decision notePriority is given to scientific evidence for existing interventions, but absence of conclusive evidence does not automatically preclude coverage if professional standards or convincing expert opinion support effectiveness.

Policy Summary

PayerUniversity Health Alliance (HSA)

PolicyMedical Necessity Determination (Coverage Criteria)

Policy CodePolicy MPP-0102-130701

Change TypeNo material changes

Effective DateAug 10, 2021

Last ReviewAug 10, 2021

Next Review Date

Key ActionProviders may request reconsideration and peer-to-peer clinical review when coverage is denied for medical necessity.

SourceLink

On This Page

Documentation Required

Documentation must support billed services

Documentation must support the level of service reported; cloned or prepopulated verbiage that lacks pertinent real‑time information does not support medical necessity. Diagnosis documentation alone is often insufficient to document medical necessity.

Support billed E/M level with contemporaneous clinical documentation.
Avoid cloned/prepopulated notes that do not provide pertinent real‑time information.

Denial Risk

Denial triggers for insufficient documentation or non‑necessity

Services may be denied or adjusted when documentation does not support the level of service billed or when treatment is not medically necessary per UHA standards; during an audit UHA will deny or adjust E/M services that exceed the patient's documented needs.

Denials/adjustments occur if documentation fails to substantiate billed services or level of care.
Burden is on patient and provider to show an individual differs from the usual case when UHA finds a treatment not medically necessary.

inv-10: Scientific evidence — hierarchy and acceptable study designs

Hierarchy (top priority)Controlled clinical trials that directly or indirectly demonstrate the intervention's effect on health outcomes; peer-reviewed studies in indexed journals.

If trials unavailableObservational studies that demonstrate a causal relationship between the intervention and health outcomes may be used.

Lower-level/adjunct sourcesPartially controlled observational studies, uncontrolled clinical series, peer-reviewed abstracts, standard reference compendia, and federal agency research may be suggestive or supportive but are lower in the evidence hierarchy.

When no scientific evidenceProfessional standards of care are considered next; if those are absent, outdated, or contradictory, expert opinion guides decisions.

Evidence sources examplesIndexed peer-reviewed journals, biomedical compendia (Index Medicus/EMBASE/Medline), recognized medical journals, standard reference compendia, federal research findings, and peer-reviewed meeting abstracts.

inv-11: Effective — definition meaning benefits outweigh harms

DefinitionEffective means a health intervention that may reasonably be expected to produce the intended results and to have expected benefits that outweigh potential harmful effects.

Determination basisEffectiveness for existing interventions is determined first by scientific evidence; if none, by professional standards of care; if those are lacking or contradictory, by expert opinion.

Clinical judgment factorsAssessment considers benefits versus harms, appropriateness of type/frequency/extent/site/duration, and applicability to the individual patient's characteristics.

Cost-effectiveness interplayAn intervention considered effective is also evaluated for cost-effectiveness relative to alternatives, but cost-effectiveness does not necessarily mean the lowest price.