When your health insurance company won’t pay for care your doctor says you need, it can be frightening and frustrating, but it doesn’t have to be a dead end. What you’ve received is called a medical necessity denial, and it’s one of the most common reasons your health insurance won’t pay a claim or will refuse to approve a pre-authorization request.
Before you can make a plan about what to do, you first need to understand exactly what happened. Understanding what caused the medical necessity denial will help you make a plan for how to get your health insurance to pay for the care you need.
What a Medical Necessity Denial Really Means
Sometimes a medical necessity denial means that your health plan’s reviewer doesn’t think you need the test or treatment your doctor wants you to have. Sometimes it doesn’t mean that. You have to read the fine print of the denial and perhaps make some phone calls to understand exactly what your medical necessity denial really means.
Sometimes even doctors’ offices misunderstand exactly why you’ve gotten a medical necessity denial, so don’t rely exclusively on the explanation from your doctor’s office. Investigate on your own, also.
When a Medical Necessity Denial Doesn’t Really Mean the Care Is Unnecessary
Your health plan uses medical necessity denials in several different situations, some of whichdon’t mean the health plan’s reviewers think the care you want is unnecessary. Here are some examples:
1. The health plan wants you to try less expensive alternatives first.
If you can show that you’ve tried one or more of these cheaper options and the option didn’t work, then your health plan is much more likely to approve your request for a costlier treatment option.
An example of this happened to me when I was a member of a well-known HMO. I wanted a prescription for an allergy medication that had worked well for me in the past. The HMO refused to pay for it until I first tried and failed treatment with the less expensive option ofdiphenhydramine. After I tried the diphenhydramine and found it made me too sleepy to drive or work, the HMO agreed to pay for the more expensive non-drowsy allergy prescription.
2. The health plan wants you to try less invasive or less risky alternatives first.
Let’s face it, although we’d all like to think that our surgeons wouldn’t recommend surgery if something less risky might work instead, surgeons make the bulk of their income doing surgery rather than finding ways to avoid doing surgery. The more surgeries a surgeon does, the more income he or she makes.
When seen in this light, a medical necessity denial saying your invasive or risky treatment option isn’t the “preferred” treatment option for your situation doesn’t necessarily mean your health plan will never agree to pay for the treatment your doctor is recommending. It might mean the reviewer would like to see you try a less invasive or less risky option first.
For example, before jumping straight to knee replacement surgery for your knee arthritis, your health plan reviewer might want you to try physical therapy or a Synvisc injection. If you can show that you’ve tried a knee injection and it didn’t work or it made your symptoms worse, your health plan is more likely to agree with your orthopedic surgeon that you need a knee replacement.
3. The health plan didn’t get correct information to understand why you need the treatment your doctor thinks is necessary.
When your doctor submits a claim or pre-authorization request to your health plan, your diagnosis and any procedures are usually submitted as numeric codes rather than as words. A single slip of a finger on a keyboard while handling these codes results in the health plan receiving information that doesn’t make sense.
For example, the ICD9 code for the disease rheumatoid arthritis is 714.0. Let’s say the office clerk accidentally types 814.0 for the diagnosis code. The ICD9 code 814.0 means your diagnosis is a fractured carpal bone, a broken wrist.
If you were requesting pre-authorization for an expensive injectable drug used to treat rheumatoid arthritis, you’d get a medically necessity denial in response to this request. It wouldn’t make sense to your health insurer to pay for a drug that costs thousands of dollars per month and has nothing to do with healing a fracture.
However, if you’re the patient with rheumatoid arthritis and you get a letter from your health plan saying your health insurance won’t pay for your expensive rheumatoid arthritis drug, you’ll probably be frightened, angry, and confused until you figure out that a typographical error in the insurance codes caused the problem.
4. The health plan didn’t get enough information to understand why you need the care.
If the codes above don’t supply sufficient information for your health plan reviewers to approve or deny a claim or pre-authorization request, the health plan will request more medical information from your doctor. This information can flow from your doctor’s office to your health plan via a fax, electronically, or by a telephone conversation between your doctor and your health plan’s reviewer. Sometimes a medical reviewer from your health plan will actually call your doctor’s office seeking a physician-to-physician telephone discussion to get more medical information or clarify the medical circumstances surrounding your claim or pre-authorization request.
If your doctor’s office is busy and never sends the additional information your health plan requested, sends incomplete information, or your health plan’s medical reviewer is unable to connect with your doctor, you’ll get a medical necessity denial. This happens not because your health plan’s reviewer thinks the care is unnecessary. Instead, it’s because he or she didn’t have enough information to justify the decision to approve your claim or pre-authorization request.
When a Medical Necessity Denial Really Does Mean Your Health Plan Thinks the Care Is Unnecessary
If none of the above scenarios describes your situation, it could be that your health plan reviewer really does think you don't need the care your doctor says you need.
If this is the case, do some research. Investigate alternate treatment options with your physician. Consider a second opinion. If you still think the denied care is what you need, then you can appeal your denial.
Ask your health insurer what it considers to be the preferred treatment for your particular circumstance. Ask how your health plan came to this conclusion. Most health plans have guidelines for preferred treatment options based on research, medical literature, or industry standards. However, these guidelines aren't always up-to-date with the latest research.
If your health plan sites "industry standards" as the basis for their preferred treatment guidelines, request information about how those standards are developed and the scientific research supporting the specific standard in question. Usually, industry standards are based on scientifically sound research by qualified medical organizations. However, occasionally what a health plan sites as an "industry standard" isn't based on scientifically sound research but is more like saying "everybody does it this way, so that's the standard."
If the guidelines sited by your health plan aren't based on scientifically sound medical research or are based on outdated research, then you may be able to overturn your medical necessity denial on appeal. If you and your doctor can show legitimate, respected, up-to-date scientific research from a recognized authority that supports your case and conflicts with your health plan's guidelines, you may be able to convince your health plan or an external reviewer to change it's mind about medical necessity and pay for the care your doctor thinks you need.
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