Medical Necessity Denials by Health Insurers

The Issue: What procedures and supplies are medically necessary for a given condition and specific patient are, fundamentally, matters to be determined by a medical provider with the requisite training to make these decisions. But healthcare insurers deny reimbursements based on medical necessity for a host of reasons having nothing to do with actual medical necessity, such as the desire for cost savings, misinterpretations of plan documents, reliance on insurers’ own nonpublic bulletins, and decisions by their paid medical directors.

Our solution: Under such circumstances, we do a review of the underlying plan documents and an analysis of the true medical necessity of the procedure or supply based on the literature. We then seek to have the determinations appealed, mediated, arbitrated, negotiated and, if necessary, litigated.