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.
Some states have statutory or regulatory definitions.
Most Medicaid agencies include a definition of medical necessity in their contracts with managed care organizations or in their regulations. Some insurance companies include the definition in their contracts with individuals and employers. Each of these issues is discussed below. In this case, the decision to call an ambulance was made by a police officer, not a medical professional. This is not always possible, however, and in these instances judgment calls have to be made.