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

Medical Necessity 

A service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.  ^{(2014 ACA Sample EOC Page 166) * CIGNA’s Definition  * CA WIC  §14059.5}

Medically Necessary shall mean health care services that a Physician, exercising professional clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

In accordance with generally accepted standards of medical practice, ^{Illinois Dept of Insurance Definition}

The Five Dimensions of the Medical Necessity Definition

• The contractual scope of coverage: whether proposed treatment is explicitly included or excluded in the health plan contract
• Whether the proposed treatment is consistent with professional standards of practice
• Patient safety and setting of the treatment
• Whether the treatment is medical in nature or for the convenience of the health professional or patient and family
• Treatment cost     samhsa.gov

most definitions incorporate the principle of providing services which are “reasonable and necessary” or “appropriate” in light of clinical standards of practice

Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. ^{Glossary Meeicare.Gov}   

Resources & Links

• Wikipedia – Medical Necessity
• MEDICARE EXCLUSIONS FROM COVERAGE AND AS SECONDARY PAYER Sec. 1862. [42 U.S.C. 1395y]
• When routine medical tests trigger a cascade of costly, unnecessary care  

Prior #Authorization

• Preauthorization is A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary.  Sometimes called prior authorization, prior approval or  precertification.
• Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. ^{Health Net Glossary}  * See also YOUR EOC, Evidence of Coverage!
• IMHO Insurance Companies are not doctors and a lot of people and regulators agree, thus the pending laws and investigations.
• • Exhausted by prior authorization, many patients abandon care: AMA survey
  • Prior Authorization in Medicare Advantage Plans: How Often Is It Used?  KFF 10/2018
  • Prior Authorization - Regulatory Investigation aka “preauthorization” and “precertification” KFF.org 5.20.2022
  • California Senate Bill 250  * Senator Pan   would require that insurers consult with doctors on which services require authorizations, streamline the process, less paperwork and allow patients to get the care they need faster.
    • SB 250 would require health plans to exempt physicians from prior authorization rules if they have practiced within the plan's criteria 80% of the time. ^CMA.Docs.org
  • PRIOR AUTHORIZATION REQUIREMENTS HALTED FOR CERTAIN SERVICES 
  • Parody If Health Care was honest  VIDEO
  • UnitedHealth launches ‘gold card' to ease prior authorization burden
  • Use of Prior Authorization Up in Medicare Advantage Plans, Senate Report Finds  
• See our main webpage on Medical Necessity

Resources, Links & Bibliography

• cal matters.org/new-bill-pushes-insurers-to-stop-playing-doctor
• Payer Denial Tactics — How to Confront a $20 Billion Problem
• cal matters.org/richard-pan
• cma docs.org/prior-authorization-bill
• Plaintiff whose insurer delayed surgery is awarded $14 million over opioid dependency

Oscar  #Clinical Guidelines

Appear to be in Plain English!

Medical Policies & Clinical UM Guidelines

• Like Lap Band Aetna Bulletin on Obesity Surgery (Gastric Bypass) (Lap Band)
• Cochlear Implants – Hearing
• Blue Cross  Anthem  Elevance
  • Welcome to the Clinical Criteria Page  Rx
• Blue Shield Clinical Policies
• United Health Care
• Formularies and pharmacy clinical policy bulletins  Aetna
  • Ozempic ® (semaglutide)
    • The Land That Doesn’t Need Ozempic  

How do I find a code.com ICD 9, 10, DRG, CPT, (Current Procedural Terminology) diagnosis code, Medical Billing,  coding

• Magellan – Mental Health —  Medical Necessity Guidelines for providers
  • Care Guidelines  Levels of Care – Service Definitions – Term Definitions
    • Outpatient Applied Behavior Analysis
    • Psychological Testing
  • Provider Handbook
    • See our webpage on finding a Magellan Therapist – Shrink – Psychiatrist
  • See our webpage on Mental Health

Utilization Review

Medicare coverage  Knee &Hip Replacement Requirements
—  #Grievances Medicare”

• Does Medicare cover knee replacement surgery? Fortune.com 
• Back & Forth conversation with a website visitor on Medical Necessity requirements from Medicare for Knee Replacement
• Lower Extremity Major Joint Replacement (Hip and Knee)  Medicare Requirements  CMS.Gov
• 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. ^{wikipedia.org/Unnecessary_health_care}
• medicare.gov/Surgical-Complications-Hip-Knee
  • 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
  • Corticosteroid Shots For Arthritis May Be Making It Worse, Studies Find
  • *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.
  • 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/costs
  • beckersasc.com/knee-replacement-cost-by-state