Glossary
Medical necessity
In one sentence
The standard a denial invokes when it says the drug is not needed. There is no single federal definition; in Medicaid the state writes it, and a managed care plan may not write a stricter one than the state's.
Also written as Medically necessary services.
What medical necessity actually means
This is the phrase that appears on the most GLP-1 denials and the one people most often read as a medical opinion about them. It is a contract and regulatory term, and where it comes from is worth knowing, because it is not the same everywhere.
In Medicaid the federal rules do not supply the definition. They require the state's contract with each managed care plan to specify one, and they set a ceiling on it: the plan's definition may be no more restrictive than the state's own, including on limits that are not expressed as numbers. So the question of whether a plan applied the right standard has an answer, and the answer is in the state's own materials rather than in the plan's letter.
A denial letter has to tell you which criterion was applied, and give it to you free if you ask. Our answer on that is linked below.
The text it comes from
This is the wording the definition rests on. Where it decides anything for you, read the section rather than our summary of it.
The state defines it and the plan may not tighten it. Each state contract must "Specify what constitutes 'medically necessary services' in a manner that— (i) Is no more restrictive than that used in the State Medicaid program, including quantitative and non-quantitative treatment limits, as indicated in State statutes and regulations, the State Plan, and other State policy and procedures."
42 CFR §438.210(a)(5), Electronic Code of Federal Regulations, effective August 2026 · source
Where this comes from
- 42 CFR §438.210(a)(5), Electronic Code of Federal Regulations, effective August 2026 — www.ecfr.gov/current/title-42/part-438/section-438.210
Where this comes up
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page says what a published rule means by a word. Which rulebook governs you depends on your plan, and your own notice and plan documents govern your case.