What Do You Mean It's Not Covered: How Major Medical Policies Define "Medically Necessary"

The phrase to watch here is "medically necessary." Your definition of what's -- even your doctor's -- may be different than your insurance company's. And, short of a lawsuit, the company's is the one that matters most. Your agent should be able to tell you about a particular company's reputation for defining terms like this. If you've had very much experience at all with health insurance, you know that most common application of the term "medically necessary" involves disputes over experimental coverage. The 1991 Alabama Supreme Court case -- Jack J. Griffis v. Blue Cross and Blue Shield of Alabama -- shows why it's such a big deal. In 1986, Jack Griffis underwent a magnetic resonance imaging scan (MRI) to measure the progression of cancer of the prostate. The test was prescribed by Dr. Thomas Moody and performed and interpreted by Dr. Robert Naftel, a qualified diagnostic radiologist. Griffis submitted a claim to Blue Cross and Blue Shield of Alabama for the cost of the MRI. Blue Cross denied coverage, based on a provision in Griffis's policy that excluded benefits for procedures considered by Blue Cross to be "experimental" or "investigative." That provision, in pertinent part, stated: We will not provide benefits for the following, whether or not a physician performs or prescribes them: ... Any treatment, procedure, facilities, drugs, drug usage, equipment, or supplies which are experimental or investigative. The policy defined "experimental" or "investigative" as follows: Experimental or investigative means any treatment, procedure, facility, equipment, drugs, drug usage, or supplies either (a) not recognized by us as having scientifically established medical value and [as] being in accordance with generally accepted standards of medical practice or (b) not approved by a governmental agency from which approval is required.