How Do MCOs Decide Whether an Intervention is Medically Necessary?

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Medical directors consult a number of sources to define coverage limits for new and standard medical interventions, including technology assessment reports, the results ofrandomized trials, and professional guidelines,according to the findings of a research project funded by The Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) initiative. The vast majority of medical directors reported that cost considerations also entered into their decision-making process.