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Medicare pays for medical items and services that are "reasonable and necessary" or "appropriate" for a variety of purposes. [1] By statute, Medicare may pay only 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 there is another statutory authorization for payment.
Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
Physician's News Digest article on Certificates of Medical Necessity; Statutory definition of a CMN at the SSA website; Medicare manual that provides exhaustive information about the practical use of CMNs, particularly section 5.3. This is the official source of information for contractors administering the Medicare system about the use of CMNs.
A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. [2] Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4]
Over the last century, delivery by Caesarean section (CS) has become increasingly safer; the medical reasons, therefore, for selecting a CS delivery over a vaginal birth are less likely to be those of necessity, and more likely to be motivated by other factors, such as considerations of pain in vaginal delivery and the effects of childbirth on ...
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Plates vi & vii of the Edwin Smith Papyrus (around the 17th century BC), among the earliest medical guidelines. A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare.
surgery (though deemed by some as inappropriate) S 1: first heart sound: S 2: second heart sound: S 3: third heart sound S 4: fourth heart sound S&O: salpingo-oophorectomy Sb: Scholar batch SAAG: serum–ascites albumin gradient SAB: staphylococcal bacteremia spontaneous abortion (that is, miscarriage) SAD: seasonal affective disorder ...