| Year |
Author |
Title, Source |
Summary/Abstract |
Medical Necessity Definition1 |
| 1994 |
Sabin, James E. and Norman Daniels |
"Determining 'Medical Necessity' in Mental Health Practice"
Hastings Center Report 24(6):5-13 |
The authors posed the question, "Should mental health insurance cover only disorders found in DSM-IV, or should it be extended to treatment for ordinary shyness, unhappiness, and other responses to life's hard knocks?" Through the use of six illustrative case studies, the authors examined the reasoning behind the determinations of medical necessity. The article includes a discussion of a recurrent conflict between "hard-line" and "expansive" views of medical necessity, noting that it frequently reflects unrecognized moral disagreement about the targets of clinical intervention and the ultimate goals of psychiatric treatment. The authors present three models for defining medical necessity and argue a defensible rationale for the "normal" model, which comprises a target of a medically defined deviation intended to decrease the impact of disease or disability. Three tests of medical necessity are offered: (1) Does it make distinctions the public and clinicians regard as fair? (2) Can it be administered in the real world? (3) Does it lead to results that society can afford? The authors conclude that the DSM-IV standard provides workable boundaries for medical necessity definitions. |
Those mental health services that are essential for the treatment of a Member's mental health disorder as defined by the DSM-IV in accordance with generally accepted mental health practice. |
| 1998 |
Chodoff, Paul |
"Medical Necessity and Psychotherapy" Psychiatric Services 49(11):1481-1483 |
Managed care and, specifically, the need to conform to medical necessity requirements have had a dramatic effect on the medical and psychiatric practice, especially on psychotherapy. The author describes the progression of the concept of medical necessity from a simple accounting of services reimbursable by insurance companies to an ambiguous term without definitional consensus. He describes its relationship to the medical model and discusses the incongruity between medical necessity and certain aspects of psychotherapy. He proposes a broader concept-health necessity-based on an evaluation of the advantages, disadvantages, and costs of medical and psychiatric services. |
"Health Necessity" would rely on medical criteria when they are relevant but would also acknowledge that the health of the citizenry can be perceived in broader terms. A theoretical foundation for this concept may be found in the biopsychosocial model. Health necessity would be based on three broad fundamentals: uniform qualifications for practitioners, acceptable professional identities, and competence; criteria for the kinds of services that would be provided and covered; and a fair mechanism for resolution of disputes about questions of service coverage. The criteria for services would include biotechnical medical criteria when appropriate, as would be the case in most ordinary medical practice, but they would be acknowledged to be only a subset of the health necessity criteria. For mental health needs, a broad range of services could also be considered, including appropriate psychotherapy for individuals who may not fit comfortably with DSM-IV diagnostic categories but who suffer a significant degree of distress and interpersonal impairment. |
| 1998 |
Ford, William |
"Medical Necessity: Its Impact in Managed Mental Health Care" Psychiatric Services 49(2):183-184 |
Discusses the impact of managed care medical necessity definitions on psychiatric care. Points to some possible reasons why MBHOs focus on cutting short-term costs rather than managing long-term costs, including short contract terms and labor-intensive reviews. |
"Treatment necessity" or "clinical necessity" would require that, to qualify for payment, a service must be: for the treatment of mental illness and substance use disorders, or symptoms of these disorders, and impairments in day-to-day functioning related to them; for the purpose of preventing the need for a more intensive level of mental health and substance abuse care; for the purpose of preventing relapse of persons with mental illness and substance abuse disorders; efficient, in the sense that a less expensive treatment works as well as a more expensive treatment; and not for the patient's or provider's convenience. |
1999 |
Singer, Sara J., Linda A. Bergthold, Carol Vorhaus, Alain Enthoven, et al. |
"Decreasing Variation in Medical Necessity Decision Making"
Stanford University, August, 1999
|
This is an in-depth report looking into the question of medical necessity. It deals with the variation and inconsistencies of definitions that the various stakeholders have. It notes a paucity of research regarding health plan decision-making and whether medical necessity definitions play a real role in decision-making. It documents a number of conferences and original research, eventually concluding with a consensus for a model decision-making process and medical necessity definitions. It concludes by reviewing the various stakeholders, their concerns, and what actions they could take to decrease medical necessity variability. |
For contractual purposes, an intervention will be covered if it is an otherwise covered category of service, not specifically excluded, and medically necessary. An intervention is medically necessary if, as recommended by the treating physician and determined by the health plan's medical director or physician designee, it is (all of the following): a health intervention for the purpose of treating a medical condition; the most appropriate supply or level of service, considering potential benefits and harms to the patient; and known to be effective in improving health outcomes. For new interventions, effectiveness is determined by scientific evidence. For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, then by expert opinion; and the cost-effectiveness for this intervention is compared to alternative interventions, including no intervention. "Cost-effective" does not necessarily mean lowest price. An intervention may be medically indicated yet not be a covered benefit or meet this contractual definition of medical necessity. A health plan may choose to cover interventions that do not meet this contractual definition of medical necessity. |
| 1999 |
Ireys, Henry T., Elizabeth Wehr, and Robert E. Cooke |
"Defining Medical Necessity: Strategies for Promoting Access to Quality Care for Persons with Developmental Disabilities, Mental Retardation, and Other Special Health Care Needs"
National Center for Education in Maternal and Child Health, Georgetown University
|
Discusses medical necessity determinations in regards to persons with developmental disabilities. The report has a flow chart showing the dynamics of medical necessity decisions within current service systems. It also provides its own specifications for determining medical necessity. |
A covered service or item is medically necessary if it will do, or is reasonably expected to do, one or more of the following: arrive at a correct medical diagnosis; prevent the onset of an illness, condition, injury, or disability (in the individual or in covered relatives, as appropriate); reduce, correct, or ameliorate the physical, mental, developmental, or behavioral effects of an illness, condition, injury, or disability; and assist the individual to achieve or maintain sufficient functional capacity to perform age-appropriate or developmentally appropriate daily activities. The MCO or insurer must determine medical necessity on the basis of health information provided by the following persons: the individual (as appropriate to his or her age and communicative abilities), the individual's family, the primary care physician, and consultants with appropriate specialty training, as well as other providers, programs, multidisciplinary teams, educational institutions, or agencies that have evaluated the individual. The determination of medical necessity must be made on an individual basis and must consider the functional capacity of the person and those capacities that are appropriate for persons of the same age or developmental level and available research findings, health care practice guidelines, and standards issued by professionally recognized organizations or governmental agencies. Final determinations will be made by a physician in concert with the following persons: the individual's primary care physician; a consultant with experience appropriate to the individual's age, disability or chronic condition; and the individual and/or family. Medically necessary services must be delivered in a setting that is appropriate to the specific health needs of the individual. |
| 1999 |
National Health Law Program |
"Medical Necessity Definition, Model Medicaid Managed Care Contract Provisions" |
|
Medically necessary care is the care which, in the opinion of the treating physician, is reasonably needed: to prevent the onset or worsening of an illness, condition, or disability; to establish a diagnosis; to provide palliative, curative, or restorative treatment for physical and/or mental health conditions; and to assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age. |
| 1999 |
Corlin, Richard |
"Statement of the AMA to the Committee on Health, Education, Labor and Pensions, U.S. Senate" |
|
"Medical necessity" means: "Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site, and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider." |
| 2000 |
Ford, William |
"Medical Necessity and Psychiatric Managed Care"
The Psychiatric Clinics of North America 23(2):309-317
|
The concept of medical necessity is one tool used by third-party payers to contain their financial risk in a seemingly nonarbitrary manner. The definitions tend to reflect corporation philosophies that would need to change to achieve real parity. |
Comprehensive reform to increase commercial psychiatric insurance coverage must include changing the definition of medical necessity by reorienting insurers from an acute care model to a model that provides both care for acute episodes and longer-term care designed to manage chronic conditions. Such longer-term management includes delivering services designed to avoidnfuture acute episodes. Commercial insurance ought to understand that a legitimate function of psychiatric services is to maintain behavioral health in addition to returning someone to health after an acute episode. Ford proposed the concept of "treatment necessity" or "clinical necessity" to encompass this broader view of the goals of psychiatric services. Treatment necessity requires a service to be: for the treatment of mental illness and substance abuse disorders, or symptoms of these disorders, and impairments in day-to-day functioning related to them; for the purpose of preventing the need for a more intensive level of psychiatric care; for the purpose of preventing relapse of persons with psychiatric disorders; consistent with generally accepted clinical practice for psychiatric disorders; and not solely for the patient's or provider's convenience. |
| 2000 |
Fleishman, Martin |
"What is Psychiatric 'Medical Necessity'?"
Psychiatric Services 51(6):711-712, 719
|
Reviews AMA's definition of medical necessity and points out problems with its application to psychiatry. Recommends its own definition for psychiatry after a discussion of HIPAA law and possible implications for fraud in psychiatry. |
AMA council on medical service defined medically necessary treatment as: health care products or services that a prudent physician would provide to a patient for the purpose of diagnosing or treating an illness, injury, disease, or its symptoms in a manner that is: (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in type, frequency, level, site, and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider. |
| 2001 |
Force, C. T. |
"A Strong and Consistent Definition of Medical Necessity Forms the Core of Meaningful Patient Protections"
Consortium for Citizens with Disabilities
|
|
The CCD believes that a federal definition of medical necessity should require plans to cover services that are: calculated to prevent, diagnose, correct, or ameliorate a physical or mental condition that threatens life, causes pain or suffering, or results in illness, disability, or infirmity; calculated to maintain or preclude deterioration of health or functional ability; individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness, disability, or injury under treatment; not in excess of the individual's needs; necessary and consistent with generally accepted professional medical standards as determined by the Secretary of Health and Human Services or the state Department of Health; and reflective of the level of service that can be safely provided and for which no equally effective treatment is available. |
| 2000 |
American Medical Association |
AMA Model Provider Contract |
|
Section 1.9 defines medically necessary/medical necessity as health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (1) in accordance with generally accepted standards of medical practice; (2) clinically appropriate in terms of type, frequency, extent, site, and duration; and (3) not primarily for the convenience of the patient, physician, or other health care provider. |
