“Medically necessary” defined. “Medically necessary” means health care services or products that a prudent physician would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:
1. Provided in accordance with generally accepted standards of medical practice;
2. Clinically appropriate with regard to type, frequency, extent, location and duration;
3. Not primarily provided for the convenience of the patient, physician or other provider of health care;
4. Required to improve a specific health condition of an insured or to preserve his existing state of health; and
5. The most clinically appropriate level of health care that may be safely provided to the insured.
Last modified: February 27, 2006