What Does”Medical Necessity” Mean to an Insurance Company – Here are Some Guidelines and Criteria

Insurance Companies’ Medical Necessity Guidelines/Criteria

For patients seeking treatment of a severe mental illness such as an eating disorder, you will have to research the medically appropriate treatment for your needs and treatment provider. What you probably will not be told until you file a claim or seek authorization for insurance benefits, is that insurance companies and administrators have their own medical criteria or level of care guidelines which will be applied to your claim or request for authorization of benefits. Almost universally, insurance companies and employers do not disclose these guidelines and criteria in group health plans or insurance policies. Therefore, claimants are left in the dark as to what the insurance company is using to decide whether to pay your claim or approve your request for authorization.

To help you navigate through the process, here are links to the criteria or guidelines for some insurers and administrators that are available online:

United Behavioral Health (UBH) https://www.ubhonline.com/html/coverageDeterminationGuidelines.html

Anthem Blue Cross (California) http://www.anthem.com/ca/provider/f1/s0/t0/pw_e175468.pdf?refer=provider

Cigna http://www.cignabehavioral.com/web/basicsite/provider/pdf/levelOfCareGuidelines.pdf

Value Options http://www.valueoptions.com/providers/Handbook/clinical_criteria.htm

Magellan http://www.magellanprovider.com/MHS/MGL/providing_care/clinical_guidelines/MNC.asp

You will note that some insurers, such as Cigna, do not have specific guidelines for eating disorders but rather have guidelines only for levels of care.

The National Eating Disorder Association (“NEDA”) toolkit provides a useful reference for explaining levels of care (http://www.nationaleatingdisorders.org/uploads/file/toolkits/NEDA-TKP-B04-TreatmentSettingsAndCare.pdf):

Inpatient Patient is medically unstable as determined by:
– Unstable or depressed vital signs – Laboratory findings presenting acute health risk – Complications due to coexisting medical problems such as diabetes Patient is psychiatrically unstable as determined by:
– Rapidly worsening symptoms – Suicidal and unable to contract for safety
Residential (RTC)
Patient is medically stable and requires no intensive medical
Patient is psychiatrically impaired and unable to respond
to partial hospital or outpatient treatment.

Partial Hospital (PHP)
Patient is medically stable but:
– Eating disorder impairs functioning, though without
immediate risk – Needs daily assessment of physiologic and mental status Patient is psychiatrically stable but:
– Unable to function in normal social, educational, or vocational situations – Engages in daily binge eating, purging, fasting or very limited food intake, or other pathogenic weight control techniques
Intensive Outpatient/Outpatient (IOP or Outpatient)
Patient is medically stable and:
– No longer needs daily medical monitoring Patient is psychiatrically stable and has:
– Symptoms under sufficient control to be able to function in normal social, educational, or vocational situations and
continue to make progress in recovery
One important bit of advice is to always try and engage your physician in helping to establish what he or she believes is medically necessary. You doctor is looking out for your best interests, insurance companies usually are not. Still, the insurance company may persist in disagreeing with your doctor, but at least you will have evidence supporting your position should you need to appeal an administrative denial or file a lawsuit.

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