Health Insurance Claim Articles

Is Your Treatment or Care Medically Necessary?

By Jeffrey L. Greyber, Esq.

In the health insurance and long-term care insurance arenas, an all-too-common basis for claim denial is that the subject treatment or care was not medically necessary. “Medical necessity” is an amorphous concept, for several reasons. Perhaps the most obvious reason is that treatment plans often account for the individual just as much (if not more) than the diagnosis; i.e., a particular kind of treatment may be necessary for one of two patients presenting with the same condition, but not for the other. And insurance companies understandably struggle with defining that which simply does not fit a mold. Some insurance companies strive to specifically define “medical necessity” … for example, I have seen “medical necessity” defined as a service or supply that is “(a) … ordered by a doctor; (b) … commonly and customarily recognized throughout the doctor’s profession as appropriate in the treatment of the sickness or injury; (c) … neither educational nor experimental in nature nor provided primarily for research purposes; or (d) in the case of hospital confinement[,] … not allocable to scholastic education or vocational training of the patient.” Conversely, some insurance companies define “medical necessity” in a general manner … for example, I have seen policies deeming treatment or care medically necessary “when, in [the insurance company’s] interpretation of accepted medical standards in [the carrier’s] service area, it cannot be omitted without adversely affecting the patient’s condition.” Regardless of whether your policy specifically or generally defines “medical necessity,” the definition will typically (and quite legitimately) be subject to varied interpretation. Alas, how does one navigate such a gray area?

The first thing for you to do (which can often be accomplished without an attorney’s involvement) is to obtain pre-approval / pre-certification of your prospective medical procedure or care, if possible. As discussed in other articles that can be found on this website, pre-approvals / pre-certifications typically do not guarantee coverage, but it certainly helps for you to obtain a pre-approval / pre-certification whenever possible. “Medical necessity” is one thing that the pre-approval / pre-certification process should be able to address if the carrier’s pre-approval / pre-certification staff is not asleep at the wheel.

If you end up requiring the assistance of an attorney to unravel an insurance company’s “medically unnecessary” denial, there are several different ways for the attorney to do so. For example, the attorney can enlist the services of medical experts to confirm the medical necessity of your treatment or care. As another example, the attorney can obtain affidavits, letters, and / or sworn statements from your treating physician or care provider regarding the medical necessity of your treatment or care. As another example, the attorney can make use of the time-tested contra proferentem doctrine – whenever contract language is ambiguous such that it is subject to more than one reasonable interpretation, such language is to be interpreted against the drafter of the contract (i.e., against the insurance company). I have yet to find an insurance contract that clearly defines “medical necessity” … just take a look at the language quoted above, it is mired in subjectivity.

If you encounter the “medically unnecessary” denial, please consider contacting us … the intake analysis is free.

Health Insurance Claim Articles