‘Medically necessary’ means health care services or products that a prudent physician would provide to a patient to prevent, diagnose or treat an illness, injury or disease, or any symptoms thereof, that are necessary and:

1.  Provided in accordance with generally accepted standards of medical practice;

2.  Clinically appropriate with regard to type, frequency, extent, location and duration;

3.  Not primarily provided for the convenience of the patient, physician or other provider of health care;

4.  Required to improve a specific health condition of an insured or to preserve the existing state of health of the insured; and

5.  The most clinically appropriate level of health care that may be safely provided to the insured.