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Why Claims Get Denied: Medical Necessity

Medical Necessity form on a table.

Recently, we published an article on denials of claims for health insurance benefits as “experimental,” one of the most-commonly-used excuses for the denial of a health insurance claim. Another commonly-provided reason for California health insurance claim denials is that the sought-after treatment is not medically necessary. Like denials based on the alleged experimental nature of the treatment, medical necessity denials are often just an insurance company strategy to save money and get patients to give up their claim. Patients with denied claims may have a right not only to the wrongly-denied treatment but also to damages through a bad-faith lawsuit. Learn more about medical necessity denials by California health insurance providers below, and contact an experienced Los Angeles bad faith insurance lawyer for more information.

What makes a treatment “medically necessary”?

You might assume that, if your doctor provides orders stating that you should receive a particular procedure or treatment, the doctor has determined that it is medically necessary. Unfortunately, insurers don’t always agree. Health insurance companies employ very restrictive definitions for what is or is not medically necessary. Most insurers consider a treatment or procedure to have “medical necessity” if a doctor, using sound clinical judgment, would provide them to a patient. The treatment or procedure has to be:

  • Done to evaluate, diagnose, or treat an injury, disease, or its symptoms, in
  • An appropriate and effective treatment for the patient’s illness or injury
  • Not done simply out of convenience, whether for the patient or health care provider, and
  • Not more expensive than other treatments or procedures that will produce similar results.

When insurers have taken “medical necessity” too far

Unfortunately for patients, this vague definition can be broadly interpreted to justify the denial of treatments that might be a patient’s best chance for making a full recovery or living a normal life. Some of the most egregious examples include:

  • Denying patients the use of the life-saving drug Harvoni to treat their Hepatitis C, except in the most severe cases of liver scarring.

  • Denying claims from amputees for microprocessor prosthetics that would make their lives easier and safer, unless they can prove they must regularly climb stairs or walk for long distances daily. A number of insurers are currently facing lawsuits over their denial of these claims based on lack of medical necessity.

If you’ve faced a wrongful claim denial by a California health insurance provider, contact the seasoned, effective, and knowledgeable Los Angeles bad faith insurance lawyers Gianelli & Morris for a free consultation on your claim at 213-489-1600.

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