‘Medical necessity’ now defined by statute

Consumers who want to appeal denial of health insurance will no longer have to use the insurance company’s definition of “medical necessity.”

The Legislature, in a bill that goes into effect today, has now put the definition into statute.

In the past, insurers filed their own definition, and often tried to slip in a clause that they have the final discretion in determining what was medically necessary. While in recent times, the state Insurance Department denied that clause, it was awkward to appeal using the insurance company’s own definition, according to Deputy Insurance Commissioner Alex Feldvebel.

So the department met with providers and insurers to come up with their own definition and after a brief tug of war, agreed upon the language in House Bill 228 which sailed through the legislature in April, and signed into law in May.

The definition, which Feldvebel described as “objective,” said that the treatment must be “consistent with general accepted standards of medical practice … clinically appropriate … demonstrated through scientific evidence … representative of best practices.” – BOB SANDERS