A service or treatment that is justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care or based strictly on plan criteria.
A service or treatment that has not successfully completed a Phase III Clinical trial, has not been approved by the FDA, or is not generally recognized as the accepted standard treatment for the disease or condition from which the patient suffers.
A medical treatment that meets nationally accepted treatment guidelines as an appropriate treatment based on scientific evidence and collaboration between medical professionals involved in the treatment of a given condition.
Evaluation of whether a service or treatment proposed by the provider is medically necessary before the provision of service based on the standard of care or plan criteria.
Evaluation of whether a hospital admission is medically necessary based on standard of care or plan criteria.
Evaluation of whether a hospital stay or stay at another facility is of an appropriate duration based on the standard of care or plan criteria.
Evaluation of whether the care provided is appropriate based on the intensity and severity of the condition such as Observation, Acute inpatient admission or ICU admission.
Evaluation of whether the service provided is consistent with the Current Procedural Terminology (CPT) code used to bill for the service.
Evaluation of whether a patient meets criteria as having an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to last or has lasted for a continuous period of not less than 12 months.
Evaluation of whether an illness, injury or disability qualifies as being caused by activities that took place in the workplace.