Medical Necessity

Medically Necessary or Medical Necessity, means health care services that a physician, exercising prudent clinical judgment, would provide to a patient or client.

The service must be:

For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
In accordance with the generally accepted standards of medical practice
Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease (Cigna, n.d.)

OT services are considered medically necessary only if there is a reasonable expectation that occupational therapy will achieve measurable improvement in the member's condition in a reasonable and predictable period of time (Medicare.gov; Kaiser Permanente, n.d.; AETNA, n.d.; Anthem, n.d.; Occupational Therapy, n.d.)

According to Blue Cross/Blue Shield (2018), active, restorative or habilitative occupational therapy has been medically proven to be effective and is medically appropriate for children suffering from a medically determinable severe or significant impairment, as determined by standardized assessments, resulting from disease, trauma, congenital anomaly or previous therapeutic processes.

A medically determinable severe delay or disorder in a child is identified by a functional impairment/deficit that adversely affects the child’s performance or a significant delay or disorder in one or more functional areas, as compared to accepted milestones for child development, which adversely affects the child’s ability to learn. Significant delays or disorders in children, are defined as:

33% delay in one functional area or a 25% delay in each of two areas; OR
If appropriate standardized instruments are individually administered in the evaluation process, a score of at least 2.0 standard deviations below the mean in one functional area; OR
score of at least 1.5 standard deviations below the mean in each of two functional areas.

Occupational Therapy. (n.d.). Retrived October 24, 2018, from http://www.aetna.com/cpb/medical/data/200_299/0250.html

Medical Necessity Definitions. (n.d.). Retrieved October 24, 2018, from https://www.cigna.com/health-care-providers/coverage-and-claims/policies/medical-necessity-definitions

Medical Policy. (2019). Retrieved November 30, 2018, from https://www.excellusbcbs.com/wps/wcm/connect/7fce4b23-92c6-4361-827e-6e72521a68ce/mp%2Bot%2Bmpc3%2B17.pdf?MOD=AJPERES&CACHEID=7fce4b23-92c6-4361-827e-6e72521a68ce

Utilization Management Document (n.d.) Kaiser Permanente (PDF)

Medical Necessity Definitions. Centers for Medicare and Medicaid (n.d.)