UMP covers services, supplies, or interventions that are:

• Included as a covered service as described in the "Benefits: What UMP Covers" section of the UMP 2009 Certificate of Coverage.
• Not excluded.
• Medically necessary.

Except as provided under "Chemical Dependency Treatment," or as decided by the statewide health technology clinical committee, a service is "medically necessary" if your treating provider recommends it and it meets all of the following conditions:

1. The purpose of the service, supply, or intervention is to treat a medical condition.
2. It is the appropriate level of service, supply, or intervention considering the potential benefits and harm to the patient.
3. The level of service, supply, or intervention is known to be effective in improving health outcomes.
4. The level of service, supply, or intervention recommended for this condition is cost-effective compared to alternative interventions, including no intervention.

For new interventions, UMP uses scientific evidence to determine effectiveness. For existing interventions, UMP first uses scientific evidence, then professional standards, then expert opinion to determine effectiveness. "Effective" means that the intervention, supply, or level of service can reasonably be expected to produce the intended results and to have expected benefits that outweigh potential harmful effects.

A health intervention is an item or service delivered or undertaken primarily to treat (that is, prevent, diagnose, detect, treat, or palliate) a medical condition (such as a disease, illness, injury, genetic or congenital defect, pregnancy, or a biological or psychological condition that lies outside the range of normal, age-appropriate human variation) or to maintain or restore functional ability. For purposes of this definition of "medical necessity," UMP does not consider a health intervention separately from the medical condition and patient indications it is applied to.

A provider may prescribe an intervention, supply, or level of service that is not a covered benefit or does not meet this definition of "medical necessity." UMP may choose to cover interventions, supplies, or services that do not meet this definition of "medical necessity"; however, UMP is not required to do so.

"Treating provider" means a health care provider who has personally evaluated the patient.

"Health outcomes" are results that affect health status as measured by the length or quality (primarily as perceived by the patient) of a person's life.

An intervention is considered new if it is not yet in widespread use for the medical condition and patient indications being considered.

Scientific evidence consists primarily of controlled clinical trials that either directly or indirectly demonstrate the effect of the intervention on health outcomes. If controlled clinical trials are not available, observational studies that demonstrate a causal relationship between the intervention and health outcomes can be used. Partially controlled observational studies and uncontrolled clinical series may be suggestive, but do not by themselves demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or potential experimental biases.

New interventions for which clinical trials have not been conducted because of epidemiological reasons (that is, rare or new diseases or orphan populations) shall be evaluated on the basis of professional standards of care or expert opinion.

For existing interventions, the scientific evidence should be considered first and, to the greatest extent possible, should be the basis for determining medical necessity. If no ­scientific evidence is available, professional standards of care should be considered. If professional standards of care do not exist, or are outdated or contradictory, decisions about existing interventions should be based on expert opinion. Giving priority to scientific evidence does not mean that UMP should deny coverage of existing interventions in the absence of conclusive scientific evidence. Existing interventions can meet UMP's definition of medical necessity in the absence of scientific evidence if there is a strong conviction of effectiveness and benefit expressed through up-to-date and consistent professional standards of care, or, in the absence of such standards, convincing expert opinion.

A level of service, supply, or intervention is considered "cost effective" if the benefits and harms relative to costs represent an economically efficient use of resources for the patients with this condition. UMP applies this criterion based on the characteristics of the individual patient. Cost-effective does not necessarily mean lowest price.

The fact a physician or other provider prescribes, orders, recommends, or approves a service or supply does not, in itself, make it medically necessary.

Preventive services not covered by the UMP preventive care benefit will still be covered under the medical benefit if medically necessary.

UMP may require proof that services and supplies, including court-ordered care, are medically necessary. No UMP benefits will be provided if that proof isn't received or isn't acceptable—or if UMP determines the service or supply is not medically necessary.