What Medical Necessity Means and How It Affects You
Whether you have a health insurance policy or if you are a member in a health plan, medical necessity is a prerequisite for coverage for all types of treatments. It is also true regardless of whether you are in a PPO, EPO or HMO. If an insured seeks coverage for a service that the insurer does not consider medically necessary, then the insurer will not provide any coverage for that service. This is true whether an insured seeks coverage after a medical service is performed or an insured seeks pre-authorization for coverage before a medical service is performed. This is why it is important to understand what medical necessity means.
“Medical Necessity” includes health care services or supplies that a healthcare worker provides for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, in accordance with the generally accepted standards of medical practice. Such services or supplies must be clinically appropriate, in terms of type, frequency, extent, site and duration, and not merely cosmetic or merely convenient for the patient or healthcare provider. “Generally accepted standards of medical practice” are standards based on credible scientific evidence that is published in peer-reviewed medical literature generally recognized by the relevant medical community and that are accepted by other healthcare workers in the community.
Insurance companies may have slightly different definitions and standards their own use when determining medical necessity. For this reason, it is always important to check a plan or policy for the relevant definition. Insurance companies and their medical directors are ultimately responsible for determining whether a service or supply is medically necessary, even if their determination is contrary to the determination of a patient’s doctor.
It is also important to note that medically beneficial is not synonymous with medically necessary. In other words, just because a procedure might treat a condition that a person has, it does not mean that the procedure is “medically necessary.” For example, if a less invasive and less expensive procedure which can treat a symptom is available, then a more costly and advanced procedure for treatment of that same symptom will not be medically necessary. Similarly, an inpatient hospitalization for a treatment will not be medically necessary if such a treatment can be provided adequately in an outpatient setting. The most common medical procedures that are generally not medically necessary are cosmetic and purely elective surgeries. These include procedures such as Botox injections, hair transplants, and plastic surgery. This being said, there are certain cosmetic procedures that are medically necessary and so it is worth seeking authorization for coverage for such surgeries from an insurer before or after the procedure.
Understanding “medical necessity” is crucial to understand which procedures or supplies an insurer might cover or pre-authorize. Without such an understanding of “medical necessity,” consumers risk seeking expensive treatments and procedures which ultimately they will have to pay for out of pocket despite the fact that they have an insurance plan or policy. However, even with an understanding of medical necessity, it is still possible that insurance companies will deny claims for coverage or pre-authorization with the excuse of medical necessity when it is not applicable.
Health Insurance Treatment Or Claims Denied For “Medical Necessity”
Before approving a service or paying a claim, health insurers normally require a showing of medical necessity. Insurers like Anthem Blue Cross and Blue Shield of California require necessity be shown before providing coverage or pre-authorization for many procedures, treatments and medical supplies. For example, Anthem Blue Cross may require patients to establish that back surgeries, organ transplants, prosthetic devices or certain mental health treatments are medically necessary before approving them. Health insurers often wrongly deny services as not medically necessary where the patients’ treating physicians have recommended the services as the most appropriate form of treatment. Health insurance companies do this to save money.
Fighting a Medical Necessity Denial based on medical necessity is generally affected by whether the insured (the person who has the insurance) has an Employee Retirement Income Security Act (“ERISA”) or non-ERISA health insurance policy. Non-ERISA insureds generally work for a government entity (teacher, police officer, firefighter, etc.), a church or purchased their insurance on their own or through Covered California. Most other insureds fall under ERISA.
Los Angeles Insurance Lawyer for Claims Denied
The Law Offices of Scott Glovsky is leading the charge in California against Anthem Blue Cross, Blue Shield of California and other insurance plans that are denying coverage to members on the basis that the services are not “medically necessary.”
“A medical necessity denial is one that insurance companies often use simply to minimize costs even though it comes at the expense of the health and interests of their members,” says Los Angeles health insurance lawyer Scott Glovsky.
The Law Offices of Scott Glovsky will help you seek justice. Click here for a free consultation.
Medical Necessity Coverage Denials Are Often Wrong
In a recent health insurance investigation, regulators reviewed a batch of coverage denials from Kaiser Permanente and found that in cases where Kaiser denied coverage, the overwhelming majority of the services sought were in fact medically necessary.
Health insurance denial lawyer Scott Glovsky says, “The intricacies of the law and how it relates to the standards and criteria that health insurance companies use to evaluate service and benefit requests are very complicated. The best action to take when an insurer denies coverage for a service that is critical to your health, your child’s health or a family member’s health is to call a health insurance denial lawyer. Although you can appeal a denial on your own, it’s worth a call to an attorney to see if they can help.
Los Angeles Health Insurance Denial Attorney Fights for Justice
The Law Offices of Scott Glovsky focuses on health insurance denials for insureds who fall into the following key categories. We help:
- Public employees – you’re a teacher, firefighter, police officer, city worker, county worker, or other public employee
- Seniors – you’re on Medicare with a private health insurance company involved or in a Medicare Advantage plan
- People who purchased insurance directly from health insurance companies
- Covered California Buyers – you purchased your plan through Covered California
- Religious Organization Employees – you work for a parish, church, diocese, synagogue, or a similar religious organization
- EPO Plan Holders – you have an exclusive provider organization (“EPO”) plan
If you fall into one of the above categories, call our office at (626) 243-5598. If you are not in one of the above categories, you are likely subject to ERISA. If you are subject to ERISA, you need to see a lawyer specializing in ERISA cases. If you have any questions about medical necessity or the denial of claims for lack of medical necessity, contact the Law Offices of Scott Glovsky for a free consultation.