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Clinical Reimbursement Criteria

Meaning

Clinical Reimbursement Criteria are the specific, non-negotiable medical and administrative standards established by health insurance payers or government health programs that must be demonstrably met for a particular medical service, procedure, or pharmaceutical to be financially covered. These criteria typically require a confirmed diagnosis, documented evidence of medical necessity, and often the failure of less expensive or conservative treatment alternatives before authorization is granted. For specialized or high-cost hormonal therapies, these rules ensure that the prescribed intervention is consistent with established clinical guidelines and is an appropriate allocation of healthcare resources.