Medical Necessity in Private Health Plans: Implications for Behavioral Health Care

Abstract

U nder basic principles that guide the American health care system, decisions regarding which particular treatments, or the amount of treatment, are medically necessary are made by medical professionals in light of their patients' condition and desires, and the state of health care knowledge. Despite all the changes that have taken place in the health system over the past generation, medical professionals remain legally and ethically obligated to make treatment recommendations that reflect sound professional judgment and that are appropriate in light of their individual patients' needs.

Exploring Personal Medicine as Part of Self-Directed Care: Expanding Perspectives on Medical Necessity

“…Placing individuals at the center of services facilitates the development of self-directed goals and identification of the personal medicine necessary to enhance their own mental health. Medical necessity is the primary criterion for determining reimbursement and has been discussed as going beyond eliminating illness or reducing symptoms to include improvements and maintenance in functioning and avoidance of functional deterioration (32).…”

Paying for Prevention: Challenges to Health Insurance Coverage for Biomedical HIV Prevention in the United States

“…Under the ACA (which reinforced preexisting state laws, 255 ERISA provisions, 256 and Department of Labor regulations), 257 insurers must provide an internal claims review and an external review process; external review procedures must meet the consumer protection standards set by the National Association of Insurance Commissioners and applicable state standards. 258 Beneficiaries may also access judicial review under either ERISA 259 or the ACA.…”

The Diagnosis of Mental Disorders in Clinical Social Work: A Review of Standards of Care

“…The precise algorithms that third parties use to determine medical necessity in the diagnosis and treatment of mental disorders have not been reported in detail, because those are proprietary, closely-held secrets (Rosenbaum, et al 2003). Yet confidential interviews with key informants from the industry, as well as a review of judicial case law, official investigations, and legal actions, support the conventional wisdom that insurers and insuring organization restrict coverage to essential treatments of mental disorders defined by the DSM, diagnosed in accordance with generally-accepted practice, and documented with a detailed description of the constellation of congruent signs and symptoms supporting each diagnosis (Rosenbaum et al, 2003).…”

“…Much as Parloff (1982) predicted in Bambi meets Godzilla, third-party standards of care for mental disorders now hinge on their diagnosis and treatment in accordance with Amedical necessity," a slippery construct that spans five dimensions, according to Rosenbaum, Kamoie, Mauery, & Walitt (2003). The first and fundamental dimension of medical necessity is a function of contractual scope, the third party's determination that its policy provides coverage for a recommended procedure or treatment, and that the recommended treatment is required to restore the patient to normal functioning.…”