To what does 'clinical judgment' refer in the review process for prior authorization?

'Clinical judgment' in the review process for prior authorization refers to the evaluation of whether alternatives are suitable. This concept emphasizes the importance of assessing the medical necessity and appropriateness of the requested treatment or service against available alternatives. When health professionals utilize clinical judgment, they consider patient-specific factors, treatment guidelines, and evidence-based practices to determine if a proposed intervention is the most effective option or if there are other feasible alternatives that could be just as beneficial for the patient.

In this context, the review process incorporates not only the clinical aspects of the treatment but also a thoughtful consideration of the patient's needs and the potential for other interventions. This careful evaluation helps ensure that prior authorization decisions align with patient care standards and optimize healthcare resource use.