A service, procedure, or medication necessary to restore or maintain physical function and
that is provided in the most cost-effective setting consistent with the member’s condition. The
fact that a provider may prescribe, administer, or recommend services or care does not make
it medically necessary. This applies even if it is not listed as a membership limitation, or an in
the Member Guidelines. To help determine medical necessity, Zion Health may request medical
records and information from licensed medical professionals.