Medical necessity (or clinical medical necessity) is largely a U.S.-based term and legal framework that broadly refers to "reasonable and necessary" or "appropriate" medical services based on evidence-based clinical standards of care.
Other countries may have medical doctrines or legal rules covering similar grounds. For example, Canada's Canada Health Act places restrictions and penalties on "extra-billing" of services and tries to ensure "services are medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability."
Medical necessity in the U.S.
Medicare may by law only pay for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member" unless another legal authorization for payment exists. Coverage criteria is determined by several policies, including National and Local Coverage Determinations. Some exceptions may be made on a case-by-case basis. However, even if a service is medically determined to be "reasonable and necessary," coverage may be limited if the service is provided more frequently than allowed under Medicare coverage policies.
As a Schedule I drug under the Controlled Substance Act, possession of cannabis is illegal as considered by the Federal government, though some states have decriminalized it. However, some chronically ill people who have used cannabis have reported benefits to their medical health, especially as a neuropathic for pain control. As such, the doctrine of medical necessity has been used by patients charged with the possession or growth of cannabis. However, cases such as United States v. Oakland Cannabis Buyers' Cooperative have led to a refusal to recognize a medical necessity exemption for cannabis regardless of any state law suggesting otherwise; other cases like Gonzales v. Raich have led to decisions recognizing the use of a medical necessity defense on an individual basis. Some states like Maryland have gone on to pass medical cannabis laws to prevent State-level criminal prosecution and imprisonment of medical cannabis users.
- Skinner, Daniel R (September/October 2013). "Defining Medical Necessity under the Patient Protection and Affordable Care Act". Public Administration Review 73 (s1): s49–s59. doi:10.1111/puar.12068. https://www.academia.edu/3522907/Defining_Medical_Necessity_under_the_Patient_Protection_and_Affordable_Care_Act.
A few elements of this article are reused from the Wikipedia article.
- Miller, Nancy W (August 2002). "What is medical necessity?". Physician's News Digest. Archived from the original on 13 April 2012. https://web.archive.org/web/20120413123747/http://www.physiciansnews.com/law/802.miller.html. Retrieved 09 August 2014.
- "Canada Health Act: R.S.C., 1985, c. C-6". Justice Laws Website. Government of Canada. 1985. http://laws-lois.justice.gc.ca/eng/acts/c-6/fulltext.html. Retrieved 09 August 2014.
- "Exclusions from Coverage and Medicare as Secondary Payer". Compilation of the Social Security Laws. Social Security Administration. http://www.ssa.gov/OP_Home/ssact/title18/1862.htm. Retrieved 09 August 2014.
- "Chapter 1, Part 3 (Sections 170 – 190.34) Coverage Determinations" (PDF). Medicare National Coverage Determinations Manual. Centers for Medicare and Medicaid Services. 23 February 2011. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part3.pdf. Retrieved 09 August 2014.
- "United States v. Oakland Cannabis Buyers' Cooperative (00-151) 532 U.S. 483 (2001) 190 F.3d 1109, reversed and remanded". Legal Information Institute. Cornell University Law School. http://www.law.cornell.edu/supct/html/00-151.ZS.html. Retrieved 09 August 2014.
- "Gonzales v. Raich (No. 03-1454) 352 F. 3d 1222, vacated and remanded". Legal Information Institute. Cornell University Law School. http://www.law.cornell.edu/supremecourt/text/03-1454. Retrieved 09 August 2014.
- "Medical Marijuana - Natalie M. LaPrade Medical Marijuana Commission". General Assembly of Maryland. 14 May 2014. http://mgaleg.maryland.gov/webmga/frmMain.aspx?pid=billpage&stab=01&id=hb0881&tab=subject3&ys=2014RS. Retrieved 09 August 2014.