From your doctor or nurse practitioner's perspective, medical necessity refers to any health service or product they prescribe for you that will prevent, diagnose or treat a condition. These services and products follow medical standards (like published guidelines, for example). From your insurance provider's perspective, a medical necessity is a term all health insurance providers use to describe the coverage they offer you.
When it comes to your medical insurance plan, it’s essential to understand the term “medical necessity.” How your insurance provider defines what is “medically necessary” is directly correlated to what covered services the plan will pay for—these services or products must fit the definition of medical necessity defined by your plan.
Keep reading to understand what medical necessity is, who determines if a procedure is medically necessary, why sometimes services deemed medically necessary by your doctor might get denied by your insurance provider—and what you can do about it.
A medical necessity applies to any number of services, from flu shots and dental exams to wheelchairs and MRIs. A doctor may attest that a service is medically necessary, therefore providing a “Letter of Medical Necessity” to your health plan for their review. The health plan determines if there will be coverage for the requested service. There are four processes for review:
Your health plan will include their definition of medical necessity within the plan. Some elements of medical necessity include:
As mentioned, your health plan’s medical policy defines what is a medical necessity. Reviewing and understanding what your specific plan deems medically necessary for particular conditions is essential. Our experts unpack all the details in our video: What Does Medical Necessity Mean, and Why Should You Care.
