Medically Necessary Services

Medically necessary services are reasonable and necessary to protect your life, keep you from becoming seriously ill or disabled, or reduce severe pain from a diagnosed disease, illness or injury.
Medically necessary services include those services that are necessary for age-appropriate growth and development, or to attain, maintain, or regain functional capacity.

For Members under 21 years of age, a service is medically necessary if it is necessary to correct or ameliorate defects and physical and mental illnesses or conditions under the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
This includes care that is necessary to fix or help relieve a physical or mental illness or condition, or maintain the member’s condition to keep it from getting worse.

Medically necessary services do not include:

  • Treatments that are untested or still being tested
  • Services or items not generally accepted as effective
  • Services outside the normal course and length of treatment or services that don’t have clinical guidelines
  • Services for caregiver or provider convenience

L.A. Care will coordinate with other programs to ensure that you receive all medically necessary services, even if those services are covered by another program and not L.A. Care.

Medically necessary services include covered services that are reasonable and necessary to:

  • Protect life;
  • Prevent significant illness or significant disability;
  • Alleviate severe pain;
  • Achieve age-appropriate growth and development; and
  • Attain, maintain, and regain functional capacity.

For Members less than 21 years of age, medically necessary services include all covered services, identified above, and any other necessary health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions, as required by the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.

EPSDT provides a broad range of prevention, diagnostic, and treatment services for low-income infants, children and adolescents under age 21.
The EPSDT benefit is more robust than the benefit for adults and is designed to assure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible.
The goal of EPSDT is to assure that individual children get the health care they need when they need it – the right care to the right child at the right time in the right setting. L.A. Care will coordinate with other programs to ensure that you receive all medically necessary services, even if those services are covered by another program and not L.A. Care.