Medical Necessity Reviews are performed by whom?

• A. A licensed medical professional
• B. A non-clinical reviewer
• C. A coder
• D. A legal professional

Answer: (A)

Medical necessity reviews rely on clinical judgment to determine whether a service is appropriate for a patient, based on the chart, diagnosis, treatment plan, and applicable payer guidelines. A licensed medical professional has the training to interpret these clinical details and decide if the care meets standard of care and payer criteria. Non-clinical reviewers focus on policy or documentation flow, coders handle billing codes, and legal professionals review for compliance risks, not the medical necessity decision. So the person performing medical necessity reviews is a licensed medical professional.