Medical Necessity

It is ValueOptions’^® policy to authorize payment only for services that are medically necessary and provided for the identification and treatment of a member’s illness.

The State of Kansas department of Social and Rehabilitative services has defined MEDICAL NECESSITY as a clinical intervention for an otherwise covered category of service, is not specifically excluded from coverage, and is medically necessary, according to all of the following criteria:

1. Authority. The clinical intervention is recommended by the treating clinician and is determined to be necessary by the Secretary or the Secretary's designee.
2. Purpose. The clinical intervention has the purpose of treating a medical condition/substance abuse disorder.
3. Scope. The clinical intervention provides the most appropriate supply or level of service, considering potential benefits and harms to the client.
4. Evidence. The clinical intervention is known to be effective in improving health outcomes. The scientific evidence for each existing intervention is to be considered first and, to the extent possible, be the basis for determinations of medical necessity. If no scientific evidence is available, professional standards of care are to be considered. If professional standards of care do not exist, or are outdated or contradictory, decisions about existing interventions are to be based on expert opinion. Coverage of existing interventions shall not be denied solely on the basis that there is an absence of conclusive scientific evidence. Existing interventions may be deemed to meet this regulation's definition of medical necessity in the absence of scientific evidence if there is a strong consensus of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or, in the absence of those standards, convincing expert opinion.
5. Value. The clinical intervention is cost-effective for this condition compared to alternative interventions, including no intervention. The term “Cost-effective'' shall not necessarily be construed to mean lowest price. An intervention may be clinically indicated and yet not be a covered benefit or meet the definition of medical necessity. Interventions that do not meet the definition of medical necessity may be covered at the choice of the Secretary or the Secretary's designee. An intervention is to be considered cost-effective if the benefits and harms relative to costs represent an economically efficient use of resources for members with this condition. In the application of this criterion to an individual case, the characteristics of the individual member is to be determinative. “Medical necessity in psychiatric situations'' means that there is medical documentation that indicates that the person could be harmful to himself or herself or others if not under psychiatric treatment or that the person is disoriented in time, place, or person.

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