A health insurer may deny coverage on “medical necessity” grounds either (a) on a pre-certification or initial admission basis or (b) in the middle of a course of a program of in-patient or other treatment (after one or more days or other sessions of a particular service have been provided on a covered basis). In either case, prompt action challenging the denials will, in my view, increase the chances of the decision being overturned by a review panel, since a case where the file is “stale” and the attending physicians may no longer be available (or interested) in being consulted on the case will be much harder to argue.
The policy of health insurance will have a definition of “medical necessity” which of course will apply and needs to be carefully reviewed in each case. In addition, may companies will publish guidelines for determination of medical necessity in behavioral health matters. Anthem Blue Cross and Blue Shield, for instance, has published guidelines for varying levels of care specifically relating to eating disorders as part of its overall behavioral health medical necessity guidelines.
In my experience, however, the stated reasons given by a health insurance company to support a determination that a particular service is not medically necessary will often have no relevance to the standards created by that insurer’s own guidelines, even though the determination letter will often state that the decision has been made in accordance with the published guidelines. Further, the reasons given by a review panel in upholding or reversing an initial determination likewise will often not track the tests established by the guidelines. Therefore, although the guidelines will be important to argue in the course of challenging a medical necessity denial by a health insurance company, it may be even more important to develop a compelling “story” of medical necessity through the report of the appropriate staff of the provider and the representatives of the patient to the review panel that is based on common sense on the particular patient’s facts and history, rather than strictly focusing on the guidelines.
In any case, it will be important to determine whether the particular health plan that covers your claim has been “grandfathered” from the protections afforded patients by recent health reform laws, or is a “non-grandfathered” plan (meaning that it must abide by the protections of the new laws and regulations). The new laws may entitle you as the patient or representative of a patient to have an *external* review by an independent panel of experts of a coverage denial based on medical necessity, so being a member of a “non-grandfathered” plan may be very advantageous. Further, if the patient remains in the care of a provider and the insurer has rejected continuation of coverage on medical necessity grounds, the patient may be entitled to demand an *expedited* (typically within 72 hours) external independent review of the coverage decision in lieu of, or in addition to, an expedited internal review by an insurer panel.
Regardless of whether the appeal is internal or external, or expedited or not, success in challenging the denial will be dependent, in my view, primarily on the willingness of the provider’s physicians and other care providers to “go to bat” for the patient. A disinterested provider, or one that is not available to spend time with the review panel, will diminish the patient’s chances of prevailing upon appeal, no matter how persuasive the patient and her representatives may feel that they are when making any written submissions to the review panel. At root, this is a matter of medical judgment, and lack of medical support for the case will play into the insurer’s hands.
Therefore, the patient and her representatives need to be pro-active with the provider and its professionals and care and insurance staff in making sure that the provider is diligently pursuing all opportunities to initiate appeals and are making the necessary medical records and reports available to the insurer in connection with appeals. And, most importantly, to solicit the support of the attending physician so that the physician is made available to the review panel when called upon to make the patient’s case.
Bringing a lawsuit to fight a coverage denial based on medical necessity may be a possibility if all internal and other avenues have been pursued to no avail, but in most cases litigation will not be cost-effective. Much more cost effective, if available, is the external independent review panel (expedited wherever possible) appeal route. If pursued diligently with the active support of the professionals under whose care the denied services are being provided, a patient will have fair chance of prevailing upon an external review, thanks to the safeguards provided by the recent reform laws.