Which statement about Medical Necessity Reviews is true?

• A. They are performed by a licensed medical professional and require specific criteria sets.
• B. They are performed by a licensed medical professional and do not require specific criteria sets.
• C. They are always done by non-clinical staff.
• D. They are not used for chronic conditions.

Answer: (B)

Medical necessity reviews rely on clinical judgment to decide whether a proposed service is appropriate for a patient. A licensed medical professional examines the patient’s medical history, current condition, and the standard of care to determine if the service is justified. While guidelines and payer policies can inform the decision, there isn’t a single universal set of criteria that must be applied in every case. The reviewer weighs the individual patient context and available evidence, rather than rigidly following a fixed checklist. This is why the statement that these reviews are performed by a licensed medical professional and do not require specific criteria sets is the best fit. It emphasizes professional clinical evaluation rather than a mandatory, universal criteria framework.