Pathology Associates Of Lexington, P.A.

Medical Necessity

General information: Saying that they are just trying to be sure that they pay only for legitimate services, claims may be rejected as "not medically necessary".
Fighting it...You may need your doctor or a hospital, hospital department, ambulance service, or other health services provider to assist you by writing a "medical necessity letter":
- it was an urgent or emergency service: you were scared or told that there may be a serious problem. So, you went to straight to your doctor's office, and "Urgent Care" facility, or an emergency room. The providers , at that point, have no choice but to give you care. They may be set up so that they can send in a "medical necessity letter" for you (see example #1, below).
- it was an elective (time to plan it) service:
  1. needed so badly you'd pay out of your pocket if had to: go ahead and get the service after you've taken photos, etc., with which you can appeal...if you want to...if payment is denied.
  2. a service you'd only buy if insurance paid most of it: unless you can get up convincing evidence of "necessity" to send in on an after-the-fact appeal, this is the type of thing you should have gotten word on from the insurer before you had the thing done.
Examples:
1. You suddenly feel terrible and almost lose consciousness but make it to a phone and call 911. The EMS service transports you to the hospital ER where you are treated and admitted to the hospital overnight and discharged home the next day. Insurance denies payment for the EMS fee, saying that 911 and EMS service was not medically necessary. You should call the ER administrator and request that they write a "medical necessity letter" to support your denial response.
2. From a billing instructor, regarding some situations: " Usually an appeal on a rejected claim which is due to a question of medical necessity requires proof for the [service provided] surgery. For instance, a breast reduction is not considered a required surgery but rather an elective procedure. I have seen claims submitted with photos and history of the problems of the patient based on back problems, etc. Also, some blephoraplasty surgeries are not considered medically necessary, but I have seen submission photos of the eyes and descriptions of the problems that patients have because of the puffiness underneath, tearing, etc. These are only a few examples."

[back to the main advisory index page] (posted 26 Aug. 2002; latest update 19 September 2004)