A Pediatric Perspective on Medical Necessity

Medical necessity is a mechanism that gives legal authority to a health plan to limit the provision of covered benefits to an enrollee.¹ Because the term medical necessity has no standardized definition, its inclusion in contract language gives the health plan considerable discretion, determining the use, scope, and duration of covered benefits. Many health care plans are endorsing the approach published by Dr Eddy in the Journal of the American Medical Association² proposing criteria for benefit coverage and medical necessity. This article suggests that health plans only be required to cover interventions for treating a medical condition. A medical condition is defined as a disease, illness, or injury, and not a biological or psychological condition within the range of normal variation. While managed care organizations may find this adult-oriented approach attractive, this approach reduces the value of preventive and supportive services that may avoid the need for future