What We Do

Medical Necessity

Medical Necessity

Making Sure the Right Care Happens at the Right Time

Medical necessity helps ensure that every test, treatment, or procedure is actually needed—and not just routine or redundant. At Comprehensive Healthcare, we use this standard to support decisions that lead to better outcomes for patients while minimizing unnecessary costs or delays.

Whether you’re a provider, employer, insurer, or policymaker, medical necessity is the common ground where quality care and smart choices meet.

What It Means

Medical necessity refers to care that a qualified physician determines is essential to evaluate, diagnose, or treat a condition. To qualify, the service must be:

  • Aligned with accepted medical standards
  • Clinically appropriate in scope and frequency
  • Not simply for patient or provider convenience
  • Cost-effective when compared to equally effective alternatives

Why It Matters

  • Claim Approval: Helps reduce the risk of insurance denials
  • Cost Savings: Avoids overuse of tests or treatments
  • Better Care: Encourages evidence-based decisions tailored to the patient

How It Works

  • Diagnosis: The provider assigns the correct ICD-10 code
  • Code Check: The diagnosis is verified against covered conditions
  • Plan Rules: Orders are reviewed for compliance with plan-specific criteria
  • Documentation: If needed, a Letter of Medical Necessity is submitted for approval

The Tools That Help

We work with industry-leading platforms to make medical necessity checks seamless:

  • Insight Medical Necessity: Real-time access to payer requirements
  • Experian Health’s Medical Necessity: Utilizing Aetna Clinical Policy Bulletins (CPB) for UM Critical Criteria to establish medical necessity

What It Means

Medical necessity refers to care that a qualified physician determines is essential to evaluate, diagnose, or treat a condition. To qualify, the service must be:

  • Aligned with accepted medical standards
  • Clinically appropriate in scope and frequency
  • Not simply for patient or provider convenience
  • Cost-effective when compared to equally effective alternatives

Why It Matters

  • Claim Approval: Helps reduce the risk of insurance denials
  • Cost Savings: Avoids overuse of tests or treatments
  • Better Care: Encourages evidence-based decisions tailored to the patient

How It Works

  • Diagnosis: The provider assigns the correct ICD-10 code
  • Code Check: The diagnosis is verified against covered conditions
  • Plan Rules: Orders are reviewed for compliance with plan-specific criteria
  • Documentation: If needed, a Letter of Medical Necessity is submitted for approval

The Tools That Help

We work with industry-leading platforms to make medical necessity checks seamless:

  • Insight Medical Necessity: Real-time access to payer requirements
  • Experian Health’s Medical Necessity: Utilizing Aetna Clinical Policy Bulletins (CPB) for UM Critical Criteria to establish medical necessity

Why Medical Necessity Matters in Healthcare

Insurance Coverage
Insurers use medical necessity to determine what gets covered. If a procedure doesn’t meet the criteria, reimbursement can be denied—leaving patients responsible for the cost.
Clinical Decision-Making
For providers, it’s a clinical checkpoint—guiding choices that align with the patient’s specific diagnosis, condition, and care plan.
Policy & Regulation
Regulators rely on medical necessity to build standards that promote fairness, protect patients, and keep healthcare accountable.
Comprehensive Healthcare Systems Inc.

What Documentation Is Required

What Documentation Is Required

When it comes to proving medical necessity, documentation makes all the difference. Here’s what needs to be in place:

  • Detailed patient symptoms and history
  • Relevant diagnostic test results
  • Clinical reasoning behind the chosen treatment
  • Supporting medical evidence or literature

Clear, accurate documentation doesn’t just support claim approval—it also reinforces quality care at every step.

Supporting the “Why” Behind the Care