Medical necessity denials refer to a decision made by a health insurance provider not to cover the cost of a medical service or procedure based on the determination that it is not deemed medically necessary. Medical directors or utilization management staff of the insurance company, who review the request and assess if the service is reasonable and essential for diagnosing or treating the patient’ s condition, determine medical necessity. The criteria for evaluating medical necessity may vary between insurance providers and include factors such as guideline-based criteria, evidence-based medicine, and the patient’s specific medical history and condition.

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