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Glossary of Health Insurance Terms To Know

Medical Necessity (Medically Necessary)

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The concept of medical necessity is used by insurers to determine whether to pay for a particular medical treatment. If the treatment is not "medically necessary," the insurer doesn't pay. There  is no clear-cut, industry wide definition of "medical necessity." 

The definition of "Medical Necessity" depends on the context and who is making the decision. The basic concept is that medically necessary services are those services which are reasonable and necessary or appropriate based on current clinical standards of care.

If a drug or treatment is optional, it is not covered. For example, plastic surgery to get rid of lines around the eyes is not "medically necessary" so it is not covered by health insurance.

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