What is "medical necessity" in health insurance policies?

"Medical necessity" in health insurance policies refers to services that are appropriate and necessary for the diagnosis or treatment of a medical condition. This concept is fundamental in the healthcare system as it helps ensure that patients receive appropriate care that is crucial for their well-being. Medical necessity is determined by considering the standard of care within the medical community, which includes factors like the efficacy of treatment, the severity of the condition, and the overall health of the patient.

In contrast, elective procedures or treatments are those that are not considered essential for the patient's immediate health needs and thus may not be covered by insurance. Alternative treatments might require special approval because they can vary widely in acceptance within the medical community compared to established practices. Likewise, the costs associated with elective surgeries often fall outside the scope of medical necessity because these surgeries are not deemed critical for the patient's health. Therefore, while these aspects are important within the realm of healthcare, they do not encapsulate the definition of medical necessity as accurately as the concept of necessary services for medical conditions.