You are the Judge. The Administrative Law Judge held in favor of the state. According to the Judge, the plaintiff had plenty of time to get to the hospital without the use of an ambulance. Thus, the ambulance was not medically necessary. The police officer was well-intentioned, but wrong.
Payment is denied.
The verdict in this case depended on whether or not the ambulance was medically necessary. This determination raises several important policy issues, each of which will be addressed below. Only those health care interventions that fit within the definition of medical necessity must be covered by the managed care organization, insurance company, or public assistance program. The definition not only determines which care will be covered and which care will not, but it also provides a legal basis for contesting wrongful denials. At the present time, there is no nationally agreed upon definition of medical necessity.