Question: Why the insurance companies have the power to deny procedures or surgeries that the patients’ doctors have decided are medically necessary?
From: Kathleen P. of Naples, Florida

Answer: As I read your question, I was reminded of times I read my health insurance policy manual but could not find a clear definition of “medically necessary.” For a treatment or procedure to be covered, it must meet the insurance company’s definition of medical necessity. There are many health plans and, it would seem, many varying definitions that are not always clear. Most insurers consider the terms “reasonable and necessary” or “appropriate clinical standards of practice” as part of the definition but these may be interpreted differently by physicians and insurers. Hospitals, physicians, and consumers wrestle with denials of treatment not meeting the definition of medical necessity. In your health insurance policy book, you may find services and procedures that are covered, excluded, and need pre-authorization. The most common reasons for medical necessity denials are the treatment is considered experimental, investigational, cosmetic, not intended for that diagnosis, or listed as non-covered. If you are arguing a medical necessity denial, make sure to document all contacts. Read your policy manual and be clear on the reason for the denial. Make sure that your physician’s office has sent all the necessary documentation, explanations, and benefits. If you and your physician feel your argument is justified, follow the denial process. You may be surprised at the results!