Which organization requires documentation to support medical necessity?

The requirement for documentation to support medical necessity is primarily established by the Centers for Medicare and Medicaid Services (CMS). This federal agency oversees the Medicare and Medicaid programs and has strict guidelines that healthcare providers must follow. Documentation of medical necessity is essential for determining whether services are reasonable, necessary, and appropriate for a patient’s specific condition, which impacts coverage and reimbursement.

CMS defines medical necessity as the need for a service or procedure that is appropriate for the diagnosis and treatment of a patient's condition. Therefore, providers must carefully document clinical information that justifies the services rendered to ensure compliance with CMS regulations. This includes detailed notes about the patient's symptoms, the rationale for chosen treatments, and related clinical findings.

The other organizations mentioned do have impactful roles in healthcare but do not focus specifically on the requirement for documentation of medical necessity in the way that CMS does. For instance, the World Health Organization (WHO) is more involved in international public health; the National Institutes of Health (NIH) primarily conducts medical research; and the American Medical Association (AMA) offers guidance and advocacy for physicians but does not establish payment policies like CMS.