Medical Necessity

Alleged lack of “medical necessity” is one of the most common reasons cited by health insurers to deny medical services and treatment. Medical necessity is a peculiar concept, in that it allows health plans to weigh economic considerations against medical ones. That is a concern, because health plans are inherently conflicted, in that they both evaluate and pay claims. Thus, when health benefits are denied, how do you know the denial is valid and not simply an attempt to pad the insurer’s bottom line?  The lawyers at DeBofsky Law have experience spotting and challenging unjustified denials of health benefits and can counsel you as to your rights.

What Is Medical Necessity?

“Medical necessity” is usually defined as a medical service or treatment that is required and cannot safely be provided in a more efficient or more economical way. A hospitalization is medically necessary if the services cannot be provided on a less restrictive basis without adversely affecting the patient’s condition. Medical necessity provisions are usually found in the “exclusions” section of your health plan.

Medical necessity can be woven into health plans in other, less obvious ways. For example, a health plan may exclude “custodial care” or “maintenance care,” which is often defined as care that is not expected to improve the patient’s condition. Such provisions were called into question in Bedrick v. Travelers, 93 F.3d 149, 151 (4th Cir. 1996), which observed that, in the case of degenerative conditions, “It is as important not to get worse as to get better.” Thus, do not assume all hope is lost if your request for care is denied, i.e., it is deemed to be “custodial” or “maintenance” in nature.

Similarly, health plans often exclude coverage for weight loss surgery, cosmetic procedures, and other elective procedures on the grounds that those procedures are not medically necessary. But complications that arise from those procedures should be covered.  See Fuller v. CBT Corp., 905 F.2d 1055 (7th Cir. 1990) (“Now even if vasectomy reversal is not a covered procedure, an illness incident to the procedure—infection, complications, a iatrogenic injury, whatever—would be covered.”). Again, it is important to consult a benefits lawyer to know your rights.

How to Challenge a Denial Based on Medical Necessity

If your health claim has been denied due to alleged lack of medical necessity, you must act quickly to protect your rights. If the health plan is governed by ERISA, you generally have no more than 180 days to appeal. You must appeal the denial of benefits in a timely manner or you may forfeit your right to later bring a lawsuit.

Where a claim has been denied based on an alleged lack of medical necessity, usually the implication is that the patient’s underlying medical condition is not severe enough to justify the service or treatment.  To avoid or overcome a denial based on medical necessity, you should submit:

• Complete medical records documenting the severity of your condition;
• Letters of support from your treating doctors explaining why the care is medically necessary;
• Medical journal articles and other resources addressing why a lesser level of care is inadequate;
• Any other documentation your health plan requests and/or which might help your case.

You do not need a lawyer to appeal a denial of health benefits, but it may be prudent to hire one depending on the amount of money involved. A lawyer can help you to determine what additional evidence or argument is needed to perfect your appeal. A lawyer can also counsel you as to alternative methods of resolving the dispute, such as negotiating a reduction or payment plan with the provider.