H Berryman Edwards, MD, FAPA

ASK DR. DENIAL

December, 1995

Dr. Brooke Thorner doesn't have e-mail yet (shame on you, Dr. Thorner) but commented at a recent CME activity on the lack of consistency in the definition of "medical necessity".

Well, Dr. Thorner, if you'd seen as many cases as I have, you'd know what it is. Actually I think of medical necessity in the insurance context the same way I think of insanity in the judicial context. It's not a medical term. It's an insurance term. And since insurance is a business, it's a business term which means it's likely to be proprietary: It can be defined any way the company wants it to be, but it has to be competitive. While writing this I looked it up in the Blue Cross benefit book that came with my personal policy. It starts out "Those Covered Services which, in the reasonable opinion of the Plan,...[Caps are theirs.] and refers to illness, treatment, standards, and appropriate setting or service. It excludes that which is primarily for convenience. I wonder how many of us compare definitions of medical necessity in determining which plan to purchase.

From the case manager's perspective their may be another parameter: the overall limitation on "mental and nervous" reimbursement. If you're trying to squeeze the most treatment out of a paltry $2000 annual benefit, you are likely to use very different definition than that used in the context of an unlimited annual benefit with a million dollar lifetime cap.

And before you start agitating to strongly for a more liberal definition (or interpretation) of the term, remember that if your practice is ever prepaid or capitated, you will be providing all that "necessary" treatment for nothing!