Criteria for decision-making in Medical Necessity IMRs

A review of a medical necessity case determines whether or not the disputed service is medically necessary based on:

1. the specific medical needs of the enrollee and



2. any of the following:
   • peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service;
   • nationally recognized professional standards;
   • expert opinion;
   • generally accepted standards of medical practice; or
   • treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious.