Question:
what are the 4 definitions of medical necessity?

hi, everyone!! i have seen posts about the 4 definitions of medical neccesity and am getting ready for a first appeal, and wonder if anyone can fill me in? thanks! darci    — darci T. (posted on August 27, 2003)

August 26, 2003
According to my endocrinologist, I fit all the critera for wls due to the fact that I am more than 100 lbs. overweight, suffer from Type 2 diabetes, obstructive sleep apnea, and have (had) elevated cholesterol, blood pressure,blood sugar levels. I am waiting for a reply from the ins. co. but in his opinion, those criteria meet the ins. co. needs for justification.
   — track

August 26, 2003
The following is right out of BC/BS insurance booklet. However, I believe these are national definitions. Look in your insurance booklet and see what they say. You could also go out to the NIH of see what they have. It is very important in a claim appeal to address this clearly if this is what they are denying you on. Anything else will just cloud the issue and they can still say you have not provided proof of medical necessity. Good Luck! <p>MEDICALLY NECESSARY means a service, treatment, procedure, equipment, drug, device or supply provided by a HOSPITAL, PHYSICIAN or other health care provider that is required to identify or treat a PARTICIPANT'S ILLNESS or INJURY and which is, as determined by BCBSUW: <p>(a.) consistent with the symptom(s) or diagnosis and treatment of the PARTICIPANT'S ILLNESS or INJURY; <p>(b.) appropriate under the standards of acceptable medical practice to treat that ILLNESS or INJURY; <p>(c.) not solely for the convenience of the PARTICIPANT, PHYSICIAN, HOSPITAL or other health care provider; and <p>(d.) the most appropriate service, treatment, procedure, equipment, drug, device or supply which can be safely provided to the PARTICIPANT and accomplishes the desired end result in the most economical manner.
   — zoedogcbr

August 26, 2003
One more comment, especially on item D. If you are on tons of meds that will likely go away and also other medical conditions that will improve and lessen the money they spend on it in the future, put together a list of the last few years of medical costs and how much of that will likely be resolved. I realize this may not be accessible to you if you have an HMO. If you have EOB's then pull the info together. It will be time consuming but worth it. Nothing like dollars and cents to get to their pocketbook. If I would have had to appeal I would have hit them with the medication savings. That alone will pay for my surgery in about 5 years. That's not even factoring in the sppointments and tests associated with those specialists. I went from about $7000 a year to around $2100 a year. I only take 2 medications now, but unfortunatley one is very expensive. For me they will likely recover their layout in 3-4 years. It really wasn't as big a deal to BC/BS as far as actual money out of their pocket as they just administer the plan for my employer as it is a self-insured plan. But for insurance companies money is the bottom line so work it to your advantage. Do not lie but reinforce the major savings, especially if it is medication realted. Meds just keep climbing in price and it is one of the hardest costs for insurance companies to control. Good Luck!
   — zoedogcbr

August 26, 2003
I'll shut up pretty soon. LOL <p>In response to the first poster, you are correct in that you meet the definition of medical necessity but when filing a claim appeal you need to get to the nitty gritty and point it out to the them one criteria at a time. Also if the policy has a clear exclusion for WLS then it does not matter how well you qualify, it will not be approved.
   — zoedogcbr

September 3, 2003
Look on different peoples profiles here. Some have appeal letters that they will let you "doctor" to your own specifications. I think Sharon Brittain, Sucy C. or WLS Deb might have some helpful info. Also, (Hope this info helps-even though you didn't ask outright for this) if you look under the library section and look up the word "profiles" There is a good question in there asking prople what obesity.com mermbers profiles were the most interesting/inspiring. (This is not worded exactly like the question, but I hope you get the point.) Look up some of the names that are listed on that question under the "find peers" section of this site, and lots of these people have other helpful info that could help in your appeal. Good Luck Becky Mulligan-PRE WLS-(consult with WLS Dr 10/23/03.)
   — bufordslipstick

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