Medical Necessity

Policy Number: GP-X-058

Last Updated: June 22, 2023 

Blue Cross and Blue Shield of Nebraska (BCBSNE), or the applicable Blue Plan, will determine whether services are medically necessary. Services will not automatically be considered medically necessary because they have been ordered or provided by a health care provider.   
Medically necessary or medical necessity is defined as health care services ordered by a treating physician exercising prudent clinical judgment, provided to a covered person for the purposes of prevention, evaluation, diagnosis or treatment of that person’s illness, injury or pregnancy that are:

  1. Consistent with the prevailing professionally recognized standards of medical practice and known to be effective in improving health care outcomes for the condition for which it is recommended or prescribed. Effectiveness will be determined by validation based upon scientific evidence, professional standards and consideration of expert opinion; and   

  2. Clinically appropriate in terms of type, frequency, extent, site and duration for the prevention, diagnosis or treatment of the covered person’s illness, injury or pregnancy. The most appropriate setting and the most appropriate level of service is that setting and that level of service, considering the potential benefits and harms to the patient. When this test is applied to the care of an inpatient, the covered person’s medical symptoms and conditions must require that treatment cannot be safely provided in a less intensive medical setting; and   

  3. Not more costly than alternative interventions, including no intervention, and are at least as likely to produce equivalent therapeutic or diagnostic results as to the prevention, diagnosis or treatment of the patient’s illness, injury or pregnancy without adversely affecting the covered person’s medical condition; and   

  4. Not provided primarily for the convenience of the following;
    1. The covered person
    2. The physician
    3. The covered person’s family   
    4. Any other person or health care provider, and 

  5. Not considered unnecessarily repetitive when performed in combination with other prevention, evaluation, diagnoses or treatment procedures.