Medical necessity determines if a medical procedure is justified. Medicare and Medicaid only cover “reasonable and necessary” procedures, while private insurers have varying definitions. Patients may battle insurers over coverage, and medical marijuana remains a debated topic due to federal laws.
Medical necessity is a United States legal doctrine that deals with determining whether or not a medical procedure is justified. Also known as clinical medical necessity, the term most commonly applies to findings obtained by the healthcare industry, i.e., insurance companies, about the reasonable need for a patient to receive a specific medical service. Medicare, Medicaid, and private insurers are often charged with deliberating and concluding on the justification of medical necessity.
Medicare and Medicaid guidelines state that they will only cover “reasonable and necessary” medical procedures. In these organizations’ terms, “reasonable and necessary” translates into any mandatory procedure or service for the diagnosis and treatment of the insured. This may also include any treatment or service intended to “improve the functioning of a malformed body member”. These clauses outline what Medicare and Medicaid consider a medical need and, by extension, worthy of coverage.
With Medicare and Medicaid, the US government will require a certificate of medical need when medical equipment is prescribed for home use. The insured, the attending physician and the medical provider must sign the certificate confirming the medical necessity of the equipment. It is then sent to the Centers for Medicare and Medicaid Services, where a decision will be made about whether the item is covered.
While the terms medical necessity may be fairly straightforward with Medicare and Medicaid, definitions of the word will vary among private insurance companies. What one company can cover, another cannot; what one plan can cover, another can’t. The fine point on insurance documents typically states exactly what the private insurer classifies as a medical necessity.
Many patients in need of medical services may find themselves battling insurers about whether they need coverage for a specific treatment. A patient soon discovers that the mere fact that his doctor considers a treatment medically necessary is not a clear indication that the patient’s insurance company will agree. For example, cosmetic surgery is rarely covered by insurance, but if the surgery can be directly attributable to improving the patient’s health – and not just her appearance – it may be considered a medical necessity.
The issue of medical marijuana has sparked the debate about medical necessity. While some doctors have testified to a patient’s need for marijuana, the courts have found that the position of the law on illegal drugs cannot be circumvented, even in cases of medical necessity. If medical marijuana is completely legal under local laws and prescribed by a doctor, the federal government can still pursue legal action against someone who uses it.
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