Medical Necessity

Example

“The insurance company denied coverage for the cosmetic surgery because it was not considered medically necessary, but approved the reconstructive surgery following her accident.”

Memory Tip

Medical Necessity = Medically Needed - if it's truly needed for health (not wants), insurance might cover it.

Why It Matters

Medical necessity determinations directly affect what treatments your insurance will pay for, potentially saving or costing you thousands of dollars. Understanding this concept helps you work with your doctor to ensure recommended treatments meet coverage criteria and avoid unexpected medical bills.

Common Misconception

Patients often assume that if their doctor recommends a treatment, insurance will automatically cover it as medically necessary. However, insurance companies make independent determinations based on their own medical policies and may deny coverage even for doctor-recommended treatments if they don't meet specific necessity criteria.

In Practice

Tom's doctor recommended an MRI for his chronic back pain, but his insurance company initially denied it as not medically necessary since he hadn't tried conservative treatments first. After completing 6 weeks of physical therapy and taking prescribed medications without improvement, his doctor resubmitted the MRI request with documentation of failed conservative care. The insurance company then approved the $2,400 MRI as medically necessary, and Tom paid only his $200 copay.

Etymology

Combines 'medical' from Latin 'medicus' meaning physician, and 'necessity' from Latin 'necessitas' meaning unavoidable or essential requirement.

Common Misspellings

Related Terms

More in insurance

Other insurance terms you should know

See Also