What does “medically necessary”, “medical necessity” & IMR mean?

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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} 

Clinical Guidelines

The Criteria (Clinical UM – Utilization Management)
for establishing the medical necessity of a service:

The service is appropriate for symptoms, diagnosis, and treatment of a condition, illness, or injury; provided for diagnosis, direct care, or treatment; in accordance with the standards of good medical practice; not primarily for the convenience of the member or member’s provider; the most appropriate supply or level of service that can be safely provided to the member. ^samhsa.gov/

Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease, and Not primarily for the convenience of the patient, Physician or other health care provider, 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.

For these purposes, generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician specialty society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors. ^{Blue Cross ppo_30_eoc Page 108}

Visit our HSA page for Federal Definition of Medical Expenses

IMR Independent Medical Review 

Knee & Hip Replacement 

FAQ’s

• Question  What do I have to do to get Medicare to approve an MRI?.
• Answer  Here’s  the  research,   but  we  can’t   really  summarize  it.
  • Magnetic Resonance Imaging  CMS
  • Aetna Clinical Bulleting MRI
  • medicare.gov/coverage/diagnostic-tests
    • Medicare Part B (Medical Insurance) covers medically necessary clinical diagnostic laboratory tests, when your doctor or practitioner orders them. These tests are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare also covers some preventive services to help prevent, find, or manage a medical problem.
  • Part B covers diagnostic non-laboratory tests when these apply:
    • Your doctor or other health care provider orders them.
    • They’re ordered as part of treating a medical problem.
      • Examples of diagnostic non-laboratory tests include CT scans, MRIs, EKGs, X-rays, and PET scans. These tests are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare also covers some preventive services to help prevent, find, or manage a medical problem.
  • Bibliography:
    • National Coverage Determination (NCD) for Magnetic Resonance Imaging
    • A spinal MRI is used to find various spinal problems, including nerve damage or tumors. It typically costs $1,000-$5,000,  Learn More

• Question Does Medicare require prior approval for back surgery?
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• Answer  Currently, Medicare does not pre-authorize coverage of any item or service that will receive payment under Part A Hospital or B Outpatient, except for custom wheelchairs. hhs.gov
• The following hospital OPD services will require prior authorization when provided on or after July 1, 2020:
  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation
• The following hospital OPD services will require prior authorization when provided on or after July 1, 2021:
  • Implanted Spinal Neurostimulators
  • Cervical Fusion with Disc Removal
• Download the full list of HCPCS codes requiring prior authorization (PDF)
• Provider Education for Required Prior Authorization (PA) Process for the Cervical Fusion with Disc Removal and Implanted Spinal Neurostimulators in the Hospital Outpatient Department (OPD) Setting
• Medicare Requires Prior Authorization for Spine Procedures prior authorization for cervical spinal fusion (CPT® codes 22551 and 22552) and implanted spinal neurostimulator procedures (CPT code 63650) when performed in the hospital outpatient department. Visit the website for more details

• Question What about Cosmetic Surgery? Liposuction?
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  Answer This is something you will have to have your doctors office review with the insurance companies.
  • Is Liposuction Covered by Health Insurance?
    • Usually liposuction is not covered by health insurance. Because liposuction is a cosmetic surgical procedure it is not covered by medical insurance unless it has some therapeutic benefit. Female breast reduction surgery is often covered by insurance because surgical breast reduction often relieves chronic pain of the back and shoulders. When female breast reduction is accomplished by tumescent liposuction, insurance may reimburse the patient a portion of the liposuction surgical fees. Similarly, sometimes health insurance will cover liposuction for the treatment of subcutaneous lipomas (small fatty tumors just beneath the skin). Liposuction.com
    • Liposuction may also be used to treat certain medical conditions, including:
      • Benign fatty tumors (lipomas).
      • Abnormal enlargement of the male breasts (gynecomastia or pseudogynecomastia).
      • Problems with metabolism of fat in the body (lipodystrophy).
      • Excessive sweating in the armpit area (axillary hyperhidrosis).
      • Liposuction is not used to treat obesity. It will not get rid of cellulite or stretch marks. A Health Me.com
        • Here’s clinical bulletins on when these Insurance Companies might consider liposuction, medically necessary:
          • Oscar – Bariatric Surgery
          • Aetna – Obesity Surgery
          • Aetna Cosmetic Surgery
          • Aetna Abdominoplasty, Suction Lipectomy
          • More clinical bulletins from Aetna