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

ERISA Ruling Reveals Big-Picture Health Benefit Issues

ERISA Ruling Reveals Big-Picture Health Benefit Issues

Unlike most industrialized countries, the U.S. does not provide universal government-sponsored health insurance coverage to all of its citizens and residents. Instead, most Americans receive coverage through their employer, while older Americans and people of lesser means receive either Medicare or Medicaid benefits. […]

7th Circuit Holds ERISA Does Not Cover Charter School Teachers

7th Circuit Holds ERISA Does Not Cover Charter School Teachers

The Employee Retirement Income Security Act impacts hundreds of millions of Americans who participate in employee benefit plans sponsored by their employers. However, as Graham v. Board of Ed. Of City of Chicago, 2021 WL 3508563 (7th Cir. Aug. 10, 2021), recently pointed out, ERISA doesn’t cover all employer-sponsored plans […]