Medical necessity

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

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.

Medical cannabis

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.

Further reading

• 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. 

Notes

A few elements of this article are reused from the Wikipedia article.