Medically necessary procedures, supplies equipment or services are those the claims administrator determines to be:

 1. Appropriate and necessary for the diagnosis or treatment of the medical condition;

 2. Provided for the diagnosis or direct care and treatment of the medical condition;

 3. Within standards of good medical practice within the organized medical community;

 4. Not primarily for your convenience, or for the convenience of your physician or another provider; and

 5. The most appropriate procedure, supply, equipment or service which can safely be provided.

The most appropriate procedure, supply, equipment or service must satisfy the following requirements:

 1. There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives;

 2. Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and

 3. For hospital stays, acute care as an inpatient is necessary due to the kind of services you are receiving or the severity of your condition, and safe and adequate care cannot be received by you as an outpatient or in a less intensified medical setting.