Medicaid Medical Necessity Guidelines

Medicaid Related Assistance
Medicaid & Long-Term Care

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What you need to know

​​​​​​The following guidelines are found in the Nebraska Administrative Code

471 NAC 1-002.02A: Medical Necessity

Nebraska Medicaid uses the following definition of medical necessity:

Health care services and supplies which are medically appropriate and:

  1. Necessary to meet the basic health needs of the client;
  2. Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;
  3. Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;
  4. Consistent with the diagnosis of the condition;
  5. Required for means other than convenience of the client or their provider;
  6. No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; and
  7. Relative to the goal of improved patient health outcomes​. 

The fact that the provider has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered.

Approval by the federal Food and Drug Administration (FDA) or similar approval does not guarantee coverage by Nebraska Medicaid. Licensure/certification of a particular provider type does not guarantee Nebraska Medicaid coverage.

For additional guidance, please refer to the Medicaid member's Heritage Health plan and the Medicaid Provider Bulletins.