(a) recommended by the health care provider;
(b) treatment for a medical condition;
(c) at an appropriate level of service or supply
(d) considered to be effective in improving health outcomes, as determined by scientific evidence, accepted standards of medical practice, or, expert opinion
(e) cost-effective for this condition compared to alternative interventions
(f) not solely for the covered person’s convenience or the convenience of the covered person’s family or physician.
The DMCB recognizes that calling an insurer's 800 number, faxing copies of medical records, completing preauthorization forms and tabbing through a web site can a dreadful and demeaning experience. That's not the point. The point is that, a live employee of the insurer is going to have to eventually read or listen to what you have to say. Physicians' chances of prevailing on behalf of Mrs. Smith will be significantly increased if that employee hears or reads the words "medically necessary" somewhere in the course of your appeal. If they know that you can argue the merits on that basis, your chances on behalf of Mrs. Smith will improve.
How not to deal with an initial denial for payment coverage for a CAT scan:
"I want to rule out a tumor, so I need this imaging study stat. Please approve"
"As a physician, I've determined that this patients' new symptom of pain could be consistent with a diagnosis of cancer. A CAT scan is the best first step imaging study to address this possibility based on my professional judgment and prevailing practice standards. There is no reasonable alternative imaging modality or other option to adequately address the diagnosis. I and my patient look forward to hearing from you shortly about coverage for this medically necessary service."