The Administrative Law Judge held in favor of the plaintiff, Barbara. According to the Judge, Barbara acted reasonably in calling an ambulance and the state must pay for it. 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. In this case, the medical need for ambulance services was defined under state law. Each of these issues is discussed below. Who Insisted They Take An Ambulance.