Being told by a payer that something is “not medically necessary” and therefore isn’t going to be covered or paid for is something patients hear all too often, please know that if your insurance denial says something like “medical necessity has not been established” the denial you are reading really says almost nothing. One of the reasons we are successful on behalf of patients is that we get to the bottom of things and find out what is the real basis for them saying “NO“.
Many of the cases we handled involve newer technologies, surgical procedures or diagnostics which are competing with very established alternatives. Payers often will favor those established procedures or therapies because they feel they have a better handle on what may or may not happen, both from a patient care point of view and (often unspoken) a cost of care point of view. The language contained in your certificate or summary plan description will broadly define “medical necessity” similar to this:
Medical necessity shall mean health care services that a physician, hospital, or other covered professional or facility provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:
a. In accordance with generally accepted standards of medical practice in the United States; and
b. Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms; and
c. Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms; and
d. Not part of or associated with scholastic education or vocational training of the patient; and e. In the case of inpatient care, only provided safely in the acute inpatient hospital setting.
For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations.
However, almost all insurers have separate medical policies or criteria which spell out in multiple paragraphs or pages their criteria for evaluating if a therapy is “medically necessary” and under what clinical conditions they will agree to cover it. That won’t usually be the same criteria as your health care provider is relying upon, based on your particular clinical situation. This is especially true when newer or more innovative therapies, devices, diagnostics, are being requested.