Surgery Is Not "Medically Necessary"

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While it sadly is a very common statement patients hear too often, if your denial only says something like “medical necessity has not been established”  it says almost nothing.  The question that must be confronted on appeal is WHY does your payer say that when your surgeon or bariatric program tell you it meets established patient selection guidelines and your insurance plan seems to broadly define “medical necessity” in terms which may be very similar to this:

“Medical necessity shall mean health care services that a physician, hospital, or other covered professional or facility provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:

a. In accordance with generally accepted standards of medical practice in the United States; and

b. Clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms; and

c. Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results for the diagnosis or treatment of that patient’s illness, injury, or disease, or its symptoms; and

d. Not part of or associated with scholastic education or vocational training of the patient; and

e. In the case of inpatient care, only provided safely in the acute inpatient hospital setting. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations.”

Denials which claim surgery is “not medically necessary” will vary since it’s always another hoop or a moving target you need to hit. 

Stop jumping through Hoops and call us at 1-877-992-7732 to discuss your appeal options in a free consultation.

601-C East Palomar Street #480 Chula Vista, California 91911 Tel - 877-992-7732 Fax - 844-384-9199

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