Understanding the Importance of Medical Necessity Data

Medical necessity data refers to the documentation and structured policy guidance used to demonstrate that a specific healthcare service, treatment, or procedure is appropriate and necessary for a patient’s diagnosis or condition. It is essential for justifying reimbursement from Medicare, Medicaid, and commercial payers.

At OnTarget Revenue, our platform transforms fragmented medical necessity sources into unified, structured data tables that align with CMS guidelines, supporting compliance and reducing denials.

Key Aspects of Medical Necessity Data

• Documentation: Includes the patient’s medical history, presenting condition, diagnosis codes, and the clinical rationale for treatment. Supports claim integrity and appeals.
• Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs): Medicare policies outlining which diagnoses support which services. Delivered in a searchable format compatible with EMRs like EPIC and Meditech.
• Medical Necessity Letters: Explain the medical justification behind a service. Platforms like Complete Check help flag when one may be needed.
• Medicare Coverage Database (MCD): The official CMS database containing all LCDs and NCDs. OnTarget Revenue syncs to it weekly.
• Evidence-Based Guidelines: Drawn from CMS, specialty societies, and literature to define what care is appropriate and necessary.

Why Is Medical Necessity Data Important?

• Claim Reimbursement: Prevents denials by ensuring claims meet payer criteria with accurate, current data.
• Patient Safety: Helps avoid unnecessary or inappropriate procedures that could pose risks.
• Regulatory Compliance: Aligns hospital practices with CMS and payer coverage rules, reducing penalties and overpayments.
• ABN Requirement Identification: Allows providers to determine whether an Advance Beneficiary Notice (ABN) is needed before service, when Medicare coverage is unlikely based on diagnosis.
• Efficient Utilization of Resources: Reduces admin burden and boosts operational efficiency by automating validation and appeals prep.

How OnTarget Revenue Supports Medical Necessity Compliance
Our Medical Necessity Data Tables and Complete Check application integrate LCDs, NCDs, ICD-10 diagnosis logic, and policy links into your workflow. We go beyond code pairs, helping providers handle high-risk, high-dollar services confidently—from labs to complex surgical claims.

We also offer customized exports for EMRs that limit hyperlinks (like Meditech) and SmartLink navigation tools for systems that support enhanced data access.

Related Resource: Learn what sets our Medical Necessity Data apart.