ALERT!  Medical Assistance proposing a new standard for deciding whether your child gets the services or equipment he or she needs

Decisions regarding whether your child gets the services or equipment he or she needs are based on "medical necessity".  Medical Assistance has just distributed a new definition of medical necessity that:

Draft definition of "medical necessity" being proposed by Medical Assistance 9/97

An intervention will be considered medically necessary if it meets ALL FOUR of the following conditions:

1. The intervention is medical in nature. Medical interventions are those that are rendered, ordered or prescribed by a licensed health care professional

2. The intervention is effective. Effective interventions are those that a reasonable practitioner would conclude that:

a. A sufficient body of scientific literature exists to demonstrate that a substantial benefit would be expected from using the intervention for the condition for which it is being prescribed, or

b. Use of the intervention for the condition for which it is being prescribed is consistent with an existing national standard of care.
 

3. The intervention is individualized. Individualized interventions are those that a reasonable practitioner would predict would provide demonstrable benefit to the individual for whom the intervention is being prescribed, given the current status of that individual.

4. The intervention is consistent with efficiency, economy and quality of care as demonstrated by:

a. It is the only effective intervention for the condition for which it is being prescribed; or

b. It is the alternative among two (2) or more effective quality interventions that a reasonable practitioner would predict would produce a substantially more beneficial outcome, given the condition for which it is being prescribed and the individual's current status; or

c. It is the most economic and quality alternative among two (2) or more equally effective interventions that a reasonable practitioner would predict would produce similar beneficial outcomes, given the condition for which it 6 being prescribed and the individual's current status.


Comments should be submitted to: Suzanne Love, Director, Bureau of Policy, Office of Medical Assistance, DPW  at  caroly@dpw.state.pa.us

This document prepared for the Web by the PA Health Law Project