CT HB05296

Establishes a definition of "medically necessary" and "medical necessity" for Connecticut's medical assistance programs administered by the Department of Social Services, effective July 1, 2010.

Requires services to prevent, identify, diagnose, treat, rehabilitate, or ameliorate medical conditions based on five criteria: generally-accepted medical standards, clinical appropriateness, lack of primary convenience purpose, cost-effectiveness compared to alternatives, and individual assessment.

Defines generally-accepted standards of medical practice as those based on credible peer-reviewed scientific evidence, physician-specialty society recommendations, views of practicing physicians in relevant clinical areas, and other relevant factors.

Specifies that clinical policies and practice guidelines may only be used as guidelines for evaluating medical necessity and cannot be the sole basis for denying service requests.

Requires the Department of Social Services to notify individuals denied services of the specific guideline or criteria used in the determination and to amend conflicting state agency regulations regarding medical necessity definitions.