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Medical Necessity

Medical necessity is the approach health insurance companies use to determine if health care services are eligible for coverage. The medical necessity review will consider if treatment is consistent with general standards of care, consistent with the patient’s diagnosis, and the most cost-efficient option available for treatment. Preventive care services may not be subject to medical necessity review.

Note: These definitions are provided only to give you a general understanding of how these words are sometimes used by health insurance companies. Please refer to your coverage documents for a complete list of defined terms that apply to your specific coverage.
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