Claim Denials on the Grounds that a Treatment is Not Medically Necessary
Part 2, Chapter 4: Traditional Individual and Group Plans, Doctors' Bills Page 18
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As we discussed earlier, some insurance companies seem to use the phrase "not medically necessary" in two different ways. In some cases, the phrase may be used to mean that the company needs additional information or documentation before it can determine whether or not a claim is eligible for coverage. In other cases, the phrase may be used to mean that the insurer has concluded that the claim is not eligible for coverage under the terms of the policy. In the former case, it would seem to make sense for the insurance company to be as specific as possible in terms of the information or documentation that's needed. However, instead of listing the specific documentation that's required, at times some insurance companies limit their explanations to the phrase "not medically necessary."
If a claim is denied on the grounds that the treatment or service is not medically necessary, and you believe that the claim should be covered by your policy, try to determine how the phrase is being used. If the insurer is requesting additional information or documentation before making a decision about the medical necessity of the treatment, you need to determine the specific documentation that the company requires. If the answer is not obvious from the EOBS, call the company and discuss the issue with a representative. Once you have determined what documentation is needed -- a letter from your doctor, a copy of an operative report, a copy of an itemized hospital bill -- file an immediate claim appeal that includes the required material.
If the insurer is using the phrase to mean that it has concluded that the treatment does not meet the requirement of medical necessity under the terms of the policy and is thus not covered, and you are convinced that the claim should be covered, ask your doctor to write a letter explaining the medical need for the treatment. Then file a claim appeal that includes the doctor's letter.
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