What is Medical Necessity Determination?
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Quick Answer
Medical Necessity Determination is the evaluation of whether a healthcare service, procedure, or medication meets clinical appropriateness standards and payer coverage criteria. AI automates this by matching clinical indicators from documentation to payer-specific medical policy criteria.
Definition
Key Points
- Matches clinical indicators to payer medical policies
- Evaluates patient-specific factors and contraindications
- Identifies supporting and contradictory evidence
- Applies payer-specific coverage criteria
- Generates medical necessity rationale with citations
- Improves first-pass approval rates significantly
Frequently Asked Questions
Who defines medical necessity criteria?
Payers define their own criteria based on CMS guidelines, clinical practice guidelines, and internal medical policies. AI systems must handle criteria variations across hundreds of payers.
How does AI handle criteria updates?
Payer criteria change frequently. AI systems with policy-native architecture can update criteria without model retraining, ensuring determinations always use current standards.
What happens when clinical evidence is incomplete?
AI identifies documentation gaps and recommends additional evidence needed to strengthen the medical necessity case, improving approval likelihood.