Who determines if something is “medically necessary”?
In reviewing claims, FIC will determine whether a service was medically necessary. We will base our decision in part on a review of your medical records. We will also evaluate medical opinions we receive. This could include the medical opinion of a professional society, peer review committee or other groups of physicians. In determining if a service is medically necessary, we will also consider reports in peer reviewed medical literature; reports and guidelines published by nationally recognized health care organizations that include supporting scientific data; professional standards of safety and effectiveness, which are generally recognized in the United States for diagnosis, care or treatment; the opinion of health professionals in the generally recognized health specialty involved; the opinion of the attending professional providers, which have credence but do not overrule contrary opinions; and any other relevant information brought to our attention. Services will be deemed medica
In reviewing pre-certification requests for your medical services, FIC will evaluate several criteria when determining whether a service is medically necessary. Some of these criteria include a review of your medical records; medical opinions (e.g. from a professional society, peer review committee, or other groups of physicians); reports in peer-reviewed medical literature; professional standards of safety and effectiveness; and clinical, peer-reviewed, nationally-accepted medical criteria. The full list of criteria that a “medically necessary” service must meet can be found in Section 3 of your Certificate of Coverage, available for download after logging in to our website. A registered nurse does an initial review of your medical service, but if the nurse is unable to confirm that it is medical necessary, the case is referred to a licensed physician for review and determination. If a service is determined to not be medically necessary, the pre-certification request will be denied. Y
