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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyVermont Medicaid Medical Necessity Coverage | Open…
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    CurrentVermont Agency of Human Services – Department of Vermont Health AccessPolicy N/A

    Medical Necessity for Covered Services

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    This rule governs when health care services covered by Vermont Medicaid are considered medically necessary, including applicable clinical standards, documentation requirements, and special considerations for EPSDT-eligible beneficiaries.

    Policy Summary
    PayerVermont Agency of Human Services – Department of Vermont Health Access
    PolicyMedical Necessity for Covered Services
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJul 1, 2020
    Next Review DateN/A
    Key ActionSupport the service with documentation in the beneficiary's medical records.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5Required elements in medical necessity
    3Bases for accepted practice standards
    Case-by-caseEPSDT determination
    AgencyFinal authority

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    Medical Necessity Coverage Criteria

    General medical necessity

    A service is medically necessary when all required elements are met.

    Medical necessity elements: The service is appropriate in type, amount, frequency, level, setting, and duration for the beneficiary's diagnosis or health condition; helps restore or maintain the beneficiary's health; prevents deterioration or palliates the beneficiary's condition; is the least costly appropriate health service available; is not solely for the convenience of the beneficiary's caregiver or a provider; and is supported by documentation in the beneficiary's medical records.

    All listed elements must be met.

    EPSDT-eligible beneficiaries

    For EPSDT-eligible beneficiaries, medical necessity also requires a case-by-case determination.

    EPSDT case-by-case purpose: The service is needed to correct or ameliorate a diagnosis or health condition, achieve proper growth and development, or prevent the onset or worsening of a health condition.

    This additional determination applies to EPSDT-eligible beneficiaries.

    Services provided solely for the convenience of the beneficiary’s caregiver or a provider do not meet the definition of medical necessity.

    Documentation and Medical Necessity Requirements

    Documentation Required

    Medical Record Support

    Providers must support medical-necessity determinations with documentation in the beneficiary’s medical records. The record should support that the service is appropriate in type, amount, frequency, level, setting, and duration for the beneficiary’s diagnosis or health condition.

    • Documentation must support how the service will help restore or maintain the beneficiary’s health, prevent deterioration, or palliate the condition.
    • Documentation should support that the service is the least costly appropriate health service available and is not provided solely for the convenience of the beneficiary’s caregiver or provider.
    Denial Risk

    Failure to Meet Medical Necessity Requirements

    A service otherwise covered by Vermont Medicaid may fail medical-necessity requirements when applicable clinical criteria or guidelines are not met, or when the service is inconsistent with generally accepted practice standards. The Agency is the final authority for medical-necessity determinations.

    • The service must meet Vermont Medicaid-adopted clinical criteria or guidelines when those criteria apply.
    • If no adopted criteria or guidelines apply, the service must be consistent with generally accepted practice standards based on credible peer-reviewed scientific evidence, physician specialty-society recommendations, or the prevailing opinion of licensed providers in the relevant clinical area.
    • For EPSDT-eligible beneficiaries, medical necessity requires a case-by-case determination that the service is needed to correct or ameliorate a diagnosis or health condition, achieve proper growth and development, or prevent the onset or worsening of a health condition.
    • Medical necessity may not be established if the service is not appropriate to the beneficiary’s condition, does not help restore or maintain health, prevent deterioration, or palliate the condition, is not the least costly appropriate available service, is solely for caregiver or provider convenience, or is not supported by the beneficiary’s medical records.

    Scope of Medical Necessity

    Medical necessity applies to health care services, including diagnostic testing, preventive services, and aftercare. Services must be appropriate in type, amount, frequency, level, setting, and duration for the beneficiary’s diagnosis or health condition, and must help restore or maintain health or prevent deterioration or palliate the condition.

    Key Definitions

    Definition
    TermAmeliorate
    MeaningTo improve or maintain a beneficiary's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
    Recognized bases
    Credible scientific evidencePublished in peer-reviewed literature.
    Physician specialty society recommendationsRecommendations issued by physician specialty societies.
    Prevailing clinical opinionThe prevailing opinion of licensed health care providers practicing in the relevant clinical area.
    Definition
    ScopeHealth care services, including diagnostic testing, preventive services, and aftercare.
    AppropriatenessAppropriate in terms of type, amount, frequency, level, setting, and duration to the beneficiary's diagnosis or health condition.
    Health benefitHelps restore or maintain the beneficiary's health.
    Prevention or palliationPrevents deterioration or palliates the beneficiary's condition.
    CostIs the least costly, appropriate health service that is available.
    Convenience and documentationIs not solely for the convenience of the beneficiary's caregiver or a provider and is supported by documentation in the beneficiary's medical records.
    Policy Summary
    PayerVermont Agency of Human Services – Department of Vermont Health Access
    PolicyMedical Necessity for Covered Services
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJul 1, 2020
    Next Review DateN/A
    Key ActionSupport the service with documentation in the beneficiary's medical records.
    SourceLink
    On This Page
    Medical Necessity Coverage CriteriaDocumentation and Medical Necessity RequirementsScope of Medical NecessityKey Definitions