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Answered 2015-07-16 18:06:33

They would start with the defintion

Medically Necessary Services or supplies provided by a licensed health facility or health professional, which are determined by the health plan company and its contracting or employed Physician Group to be: Not Experimental or Investigational. Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness or injury. Provided for the diagnosis or care and treatment of the condition, illness, or injury. Not primarily for the convenience of the Member the Member's Physician, or anyone. The most appropriate supply or level of service that can safely be provided. For example, outpatient rather than inpatient surgery may be authorized when the setting is safe and adequate.

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My Blue Cross plan required documentation of medical condition requiring breast reduction, i.e., neck pain,Back pain, etc. I had to prove that I had sought help from MD's for a period of time and that the reduction was recommended by them.

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