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

How Do I Know if My Benefit Plan Is Self-Funded?

How Do I Know if My Benefit Plan Is Self-Funded?

When the term “self-funded” is used in relation to employer-sponsored benefit plans, the term usually refers to what are known as “welfare” benefits. ERISA does not use the term “welfare” to mean public assistance. Instead, the term relates to benefits provided for the employee’s welfare; and is defined by the statute to mean […]

What Is ERISA?

What Is ERISA?

ERISA, an acronym for the Employee Retirement Income Security Act of 1974,1 is one of the most important federal laws ever passed by Congress, but hardly anyone knows what it is or what it does. […]

ERISA Ruling Shows Lax Enrollment Practices Can Be Costly

ERISA Ruling Shows Lax Enrollment Practices Can Be Costly

A life insurance decision issued by the U.S. Court of Appeals for the Eighth Circuit may be summed up by quoting a single sentence from the opinion: “Misleading an [Employee Retirement Income Security Act]-plan participant has consequences.” Skelton v. Reliance Standard Life Insurance Co.[1] teaches how lax benefit enrollment practices can be costly. […]

How Can I Tell If My Benefit Plan Is Governed by ERISA?

How Can I Tell If My Benefit Plan Is Governed by ERISA?

ERISA is an acronym for the federal Employee Retirement Income Security Act of 1974. Most people have never heard of ERISA, but its comprehensiveness impacts the vast majority of American workers and their dependents. The original intent behind ERISA’s enactment was to remedy pension plan abuses; however, just prior to Congress’ passage of the ERISA law, the scope […]