What does “medically necessary” and “medical necessity” mean?

Excerpt from Insurance Policy – EOC Evidence of Coverage

The Benefits of this Plan are provided only for Services which are Medically Necessary as defined in this section.

Services which are Medically Necessary include only those which have been established as safe and effective, are furnished under generally accepted professional standards to treat illness, injury or medical condition, and which are:

Consistent with the Plan’s medical policy;

Consistent with the symptoms or diagnosis;

Not furnished primarily for the convenience of the patient, the attending Physician or other provider; and

Furnished at the most appropriate level which can be provided safely and effectively to the patient.

If there are two (2) or more Medically Necessary Services that may be provided for the illness, injury, or medical condition, Blue Shield Life will provide benefits based on the most cost-effective Service.

Hospital Inpatient Services which are Medically Necessary include only those Services which satisfy the above requirements, require the acute bed-patient (overnight) setting, and which could not have been provided in the Physician’s office, the Outpatient department of a Hospital, or in another lesser facility without adversely affecting the patient’s condition or the quality of medical care rendered. Inpatient services not Medically Necessary include hospitalization:

For diagnostic studies that could have been provided on an Outpatient basis;

For medical observation or evaluation;

For personal comfort;

In a pain management center to treat or cure chronic pain; and

For Inpatient Rehabilitation that can be provided on an Outpatient basis. ^{Copied from Blue Shield EOC} 

Medical Necessity – Knee – Hip —  #Grievances Medicare”

• • Check this instructional bulletin for your doctor

     

    DOCUMENT MEDICAL NECESSITY TO AVOID DENIAL OF CLAIMS

    CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to other treatments. To avoid denial of claims for major joint replacement surgery, the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes should consist of more than just conclusive statements. Therefore, the medical record of the joint replacement surgical patient must specifically document a complete description of the patient’s historical and clinical findings. Both physicians and hospitals are responsible for ensuring a complete and accurate record.

    

    Joint Replacement Model extended for 3 years

  • Unnecessary health care (overutilization, overuse, or overtreatment) is health care provided with a higher volume or cost than is appropriate.[1] In the United States, where health care costs are the highest as a percentage of GDP, overuse was the predominant factor in its expense, accounting for about a third of its health care spending ($750 billion out of $2.6 trillion) in 2012.[2]

     

    Factors that drive overuse include paying health professionals more to do more (fee-for-service), defensive medicine to protect against litigiousness, and insulation from price sensitivity in instances where the consumer is not the payer—the patient receives goods and services but insurance pays for them (whether public insurance, private, or both).[3] Such factors leave many actors in the system (doctors, patients, pharmaceutical companies, device manufacturers) with inadequate incentive to restrain health care prices or overuse.[1][4] This drives payers, such as national health insurance systems or the U.S. Centers for Medicare and Medicaid Services, to focus on medical necessity as a condition for payment. However, the threshold between necessity and lack thereof can often be subjective.

    Overtreatment, in the strict sense, may refer to unnecessary medical interventions, including treatment of a self-limited condition (overdiagnosis) or to extensive treatment for a condition that requires only limited treatment.

    It is economically linked with overmedicalization. https://en.wikipedia.org/wiki/Unnecessary_health_care

  • medicare.gov/Surgical-Complications-Hip-Knee
  • This looks like the clinical bulletin for Medicare

     

    The most common reason for total knee replacement surgery is arthritis of the knee joint. Types of arthritis include
    osteoarthritis, rheumatoid arthritis and traumatic arthritis (arthritis which occurs as a result of injury). This arthritis
    causes a severe limitation in the activities of daily living, including difficulty with walking, squatting, and climbing
    stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for
    a long time. Other findings include chronic knee inflammation or swelling not relieved by rest, knee stiffness, lack of
    pain relief after taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement
    with other conservative therapies such as steroid injections and physical therapy. Osteonecrosis and malignancy are
    additional reasons to proceed with total knee replacement surgery. The goal of total knee replacement surgery is to
    relieve pain and improve or increase patient function.

    Total knee replacement surgery will be considered medically necessary when one or more of the following criteria are met:

    Unsuccessful history of appropriate conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. Non surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following:

    anti inflammatory medications,

    analgesics,

    flexibility and muscle strengthening exercises,

    supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care],

    activity restrictions as is reasonable,

    assistive device use,

    weight reduction as appropriate, therapeutic injections into the knee as appropriate.

    Documentation Requirements

    The medical record must contain documentation that fully supports the medical necessity and justification of the
    procedure performed.

    cgsmedicare.com/

  • Here are just 5 of MANY recent reports from the medical community showing that Cortisone DOES NOT FIX MY KNEE–it only masks pain and may cause damage!*Harvard Medical School, Cortisone Report, Apr. 1, 2019

     

    *WebMD, “Disadvantages of Cortisone Injections.”

    *”Cortisone Injection Risks and Side Effects,” Emmanuel Konstantakos, MD Peer Reviewed, 2016, Arthritis Health

    *Dr. McAlindon. “We now know that these injections bring no long-term benefit, and may, in fact, do more harm than good by accelerating damage to the cartilage.”
    This study was supported by the NIH’s NIAMS (R01-AR051361) and National Center for Advancing Translational Sciences

    *Repeated corticosteroid injections to the joint may speed cartilage degeneration.
    Credit Timothy E. McAlindon, M.D., M.P.H., of Tufts Medical Center, Boston.

    What complications might there be from knee replacement?
    Since my orthopedic surgeon has indicated that I need Total Knee Replacement, how can I over-ride the Medicare requirement that I have Cortisone Injections before I can have the surgery?

     

    All my extensive research shows that Cortisone is very damaging to skin, bones and surrounding tissue, just prolongs the damage to my knee, and means that I will be that much older perhaps necessitating a longer recovery.

    I am also an athlete and I am unable to participate in my numerous sports so waiting for Total Knee Replacement means it will be much harder to re-gain my fitness.

    Cortisone Injections are just another cost for Medicare (and me) when TKR will be the end result!

    kantor law.net/health-insurance-claims/

     

    See our other page on appeals

    • I don’t have a grievance yet–so will see how my Appeal for a TKR now goes, since I’ve met the qualifications of “conservative treatments” over the course of the last 2-3 years!!!
      We need to use the exact proper terms.

       

      Grievance—A complaint about the way your Medicare health plan or Medicare drug plan is giving care. For example, you may file a grievance if you have a problem calling the plan or if you’re unhappy with the way a staff person at the plan has behaved towards you. However, if you have a complaint about a plan’s refusal to cover a service, supply, or prescription, you file an appeal.

      Appeal—An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:
      ■ Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
      ■ Your request for payment for a health care service, supply, item, or prescription drug you already got
      ■ Your request to change the amount you must pay for a health care service, supply, item or prescription drug
      You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.

      medicare.gov/Appeals.pdf

    • Will see how my Appeal for a TKR now goes, since I’ve met the qualifications of “conservative treatments” over the course of the last 2-3 years!!!
      Please when using technical terms, define them and provide a URL.
      /cgsmedicare.com/

       

      CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to conservative treatments.

      Pre-surgical physical therapy progress notes are important in demonstrating how the patient has progressively worsened over a period of time. Noting that the patient has “failed conservative therapies” in the history and physical is a conclusive statement and should be supported by other specific, objective information in the patient’s medical record.

      *****
      cgsmedicare.com/total_knee_fact_sheet

      One or more of the below conservative treatments have been tried and failed for 3 months or
      more except in special circumstances where delay of definitive care is not appropriate:
      • Anti-inflammatory medication:
      Duration of treatment
      • Analgesic
      • Home exercise: Duration of treatment
      • Physical therapy: Duration of treatment
      • Use of cane or walker: Duration of treatment
      • Weight loss: Duration of treatment
      • Brace: Duration of treatment
      • Cortisone shot(s): Duration of treatment
      • Visco-supplementation: Duration of treatment

      *****

      mass.gov/knee-arthroplasty
      A summary of the non-operative, conservative treatment(s) that have been tried and have been unsuccessful in managing the patient’s condition;

      *****

      • A listing, description and outcomes of failed non-surgical treatments, such as:
      – Trial of medications (for example, Nonsteroidal anti-inflammatory drugs (NSAIDs)).
      – Weight loss.
      – Physical therapy.
      – Intra-articular injections.
      – Braces, orthotics or assistive devices.
      – Physical Therapy and/or home exercise plans.
      – Assistive devices (for example, cane, walker, braces (specify type of brace), and orthotics) cms.gov/jointreplacement

    • The average hospital charge for a total knee replacement (TKR) in the United States is $49,500 to $57,000 healthline.com/total-knee-replacement-surgery/understanding-costs#9