A common reason given for denials of health insurance coverage is a “lack of medical necessity.”  When an insurance company denies a claim on that basis, that means the insurer disagrees with the patient’s doctor and is substituting its own judgment in order to deny treatment the doctor deemed necessary for the patient’s well-being.  Medical necessity denials are especially prevalent in claims involving mental health disability, such as situations where sub-acute residential treatment is recommended to treat a variety of conditions such as substance use disorders, eating disorders, and adolescent behavioral disorders.  However, medical necessity denials occur with respect to all aspects of medical treatment.

Medical Necessity Letters Are Applicable to All Medical Claims

The way a patient can counter a denial based on a medical necessity determination is with a letter of medical necessity from the treating doctor explaining the treatment rationale and why other potential treatments are deemed less efficacious.  I recently collaborated with three other authors – Joseph Feldman, Eric Pleikun, M.D., and Cheryl Potts – to draft an article on letters of medical necessity which was published in the July 2021 issue of the Journal of Psychiatric Practice.  The article explains letters of medical necessity – their purpose and what needs to be included in such a letter, and includes a helpful guide to both patients and practitioners on how to draft a convincing letter of medical necessity.

Although the article is focused on psychiatric claims, the discussion in the journal article is applicable to all medical claims and offers guidance on how to counter an insurance company’s claim that a test, treatment, medication, or other healthcare-related service lacks medical necessity.

A copy of the full article published in the Journal of Psychiatric Practice may be found here.

Related Articles

8th Circ. Ruling Sets Road Map For Disability Benefit Reviews

8th Circ. Ruling Sets Road Map For Disability Benefit Reviews

Disability benefit cases governed by the Employee Retirement Income Security Act are not only about whether someone qualifies for benefits, but often involve benefit terminations. While many courts have confronted that situation, the guidelines for assessing ongoing disability benefit claims have varied, especially under a deferential standard of judicial review.

New ERISA Rulings Diverge On Civil Procedure

New ERISA Rulings Diverge On Civil Procedure

Over the past several months, there has been a flurry of federal appellate opinions questioning civil procedure norms in Employee Retirement Income Security Act benefits litigation.[1] A pair of brand new appellate decisions have also focused on the same issue, although not necessarily in a direction that harmonizes ERISA civil procedure with the Federal Rules of Civil Procedure.