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Medical Necessity Definitions

Medical Necessity definitions are different for physicians than for other providers, and for seniors than for other adults.

Cigna Healthcare defines Medical Necessity in the following four ways:

  • Medical Necessity for Physicians
  • Medical Necessity for other Health Care Providers
  • Health Care for Seniors Definition of Medical Necessity for Physicians
  • Health Care for Seniors Definition of Medical Necessity for other Health Care Providers

Full descriptions of each are given below.

Definition of Medical Necessity for Physicians

"Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. In accordance with the generally accepted standards of medical practice
  3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
  4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
  5. 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

For these purposes, "generally accepted standards of medical practice" means:

  1. Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
  2. Physician Specialty Society recommendations
  3. The views of physicians practicing in the relevant clinical area
  4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Seniors Definition of Medical Necessity for other Health Care Providers

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. In accordance with the generally accepted standards of medical practice
  3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
  4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
  5. 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

For these purposes, "generally accepted standards of medical practice" means:

  1. Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community
  2. Physician and Health Care Provider Specialty Society recommendations
  3. The views of physicians and health care providers practicing in relevant clinical areas
  4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Seniors Definition of Medical Necessity for Physicians

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. In accordance with the generally accepted standards of medical practice
  3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
  4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
  5. 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

For these purposes, "generally accepted standards of medical practice" means:

  1. Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
  2. Physician Specialty Society recommendations
  3. The views of physicians practicing in the relevant clinical area
  4. Any other relevant factors

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Seniors Definition of Medical Necessity for other Health Care Providers

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" shall mean health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. In accordance with the generally accepted standards of medical practice
  3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
  4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers

For these purposes, "generally accepted standards of medical practice" means:

  1. Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community
  2. Physician and Health Care Provider Specialty Society recommendations
  3. The views of physicians and health care providers practicing in relevant clinical areas
  4. Any other relevant factors

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Medical Necessity Criteria for Treatment of Mental Health and Substance Use Disorders

Cigna HealthcareSM believes that all treatment decisions that are made in alignment with the Medical Necessity Criteria must be first and foremost clinically based. Care must be patient-centered and take into account the individuals’ needs, clinical and environmental factors, and personal values.

Learn more about our Behavioral Health Guidelines.

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