Let’s talk about a term that may be unfamiliar to many people but may cause lots and lots of confusion, aggravation and stress: medical necessity.

Medical necessity is defined as “accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care,” by the American College of Medical Quality (ACMQ). One insurance provider, Cigna, has defined medical necessity as:

health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

  1. in accordance with the generally accepted standards of medical practice;
  2. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and
  3. not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.

Not exactly clear, simple definitions. But nevertheless, definitions that all healthcare providers have to go by in order to do what we can to assist people in getting the benefits coverage they seek when having a healthcare service performed, such as an imaging exam. In this situation, medical necessity can be wholly met, partially met or denied as not necessary.

As an example, for a woman who needed an MRI, not all of the medical necessity was met for coverage, according to her insurance carrier. But, as per our procedures on behalf of people who will be our patients, we worked with her medical provider to get more information regarding her diagnosis to see if all of the necessity was met.

The good news is that it was. The not-so-good is that the information from her medical provider arrived the day of her exam so our success was very last-minute.

There are few things more frustrating to a physician than a pile of medical necessity edits (an edit would be this particular scenario for a doctor where DIS as the imaging provider is asking for more information). This has become something of a major bone of contention between payers and physicians, because, often times, physicians don’t understand why their clinical judgment is being brought into question.

The reality is, payers are not always judging the clinician’s care per se, so much as they are questioning if the level of care was incorrect. The procedure or prescription may well have been appropriate for the patient – but if it was provided in the wrong care setting, a payer won’t cover those services.

Capitol Imaging Services has always worked to do what we can to assist our patients and the medical provider. Our experienced staff of insurance benefits advisors and coordinators work daily with insurance carriers, medical offices and people to resolve any issues before the day of the exam.

We may from time to time not succeed. But, our pledge to you is that we will do all we can. Click here to use our CONTACT US form to send us an email requesting information or for any questions you may have regarding insurance coverage for an imaging exam. A Capitol Imaging Services associate will be happy to assist you.

Capitol Imaging Services is doctor trusted and patient preferred.

Image used under license from freestock.com