Through this policy statement, the American Academy of Pediatrics advocates that all health care insurers adopt consistent medical necessity definitions that reflect the needs of infants, children, adolescents, and young adults (hereafter noted as "children") as a function of developmental, epidemiologic, dependency, demographic, and cost-related factors that change over the pediatric continuum and that differ from adults. Optimally, the scope of benefits defined in health care contracts should address the complete spectrum of health care needs of children and families, but in reality, many plans offer a limited scope of benefits for children. Even if a proposed intervention falls within the scope of benefits or is not specifically excluded from coverage, the health plan may still deny the intervention. In such cases, contractual language may allow an appeal to succeed if the provider demonstrates medical necessity. With the assistance of experienced pediatric physicians and other providers with pediatric expertise, health care payers and agencies should clearly detail the processes that define, evaluate, and determine medical necessity and through which providers may appeal decisions. A basic requirement for any medical necessity process is the consideration of input from the physician(s) caring for a pediatric patient for whom a medical necessity determination is necessary.

中文翻译：

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确定儿童医疗必要性的考虑因素：合同语言的应用。

通过本政策声明，美国儿科学会倡导所有医疗保健保险公司采用一致的医疗必要性定义，以反映婴儿、儿童、青少年和年轻人（以下称为“儿童”）的需求，作为发育、流行病学的函数、依赖、人口统计和成本相关因素，这些因素在儿科连续体中发生变化并且与成人不同。最佳情况下，医疗保健合同中定义的福利范围应满足儿童和家庭的全部医疗保健需求，但实际上，许多计划为儿童提供的福利范围有限。即使提议的干预措施属于福利范围或未明确排除在承保范围内，健康计划仍可能拒绝该干预措施。在这种情况下，如果提供者证明有医疗必要性，合同语言可能允许上诉成功。在经验丰富的儿科医生和其他具有儿科专业知识的提供者的帮助下，医疗保健支付者和机构应明确详细说明定义、评估和确定医疗必要性的流程，以及提供者可以通过哪些流程对决定提出上诉。任何医疗必要性流程的基本要求是考虑来自需要确定医疗必要性的儿科患者的医生的意见。并确定医疗必要性以及提供者可以通过哪些方式对决定提出上诉。任何医疗必要性流程的基本要求是考虑来自需要确定医疗必要性的儿科患者的医生的意见。并确定医疗必要性以及提供者可以通过哪些方式对决定提出上诉。任何医疗必要性流程的基本要求是考虑来自需要确定医疗必要性的儿科患者的医生的意见。