Medical necessity: do we need it?

The term medical necessity has been mainly a placeholder in insurance plans for over thirty years. More recently, the national health care reform debate and litigation over denials of costly experimental treatments have broken the term out into open discussion about what a necessary service is and w...

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Bibliographic Details
Published in:Health Affairs 1995, Vol.14 (4), p.180-190
Main Author: Bergthold, L A
Format: Article
Language:English
Subjects:
Cost analysis
Decision Making
Definitions
Health care
Health care policy
Health Care Rationing - legislation & jurisprudence
Health Care Reform
Health insurance
Insurance Claim Review
Insurance companies
Insurance coverage
Insurance, Health, Reimbursement - legislation & jurisprudence
Litigation
Managed care
Medicaid
Medical practices
Medical technology
Medicare
Patient Advocacy - legislation & jurisprudence
Patients
Physicians
Reforms
Task forces
Terminology
Terminology as Topic
United States
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Description
Summary:The term medical necessity has been mainly a placeholder in insurance plans for over thirty years. More recently, the national health care reform debate and litigation over denials of costly experimental treatments have broken the term out into open discussion about what a necessary service is and who should decide if it is covered. This paper summarizes the history of the term and its evolution from an insurance concept controlled by practicing physicians to a rationing tool used by insurance administrators. How did national reform efforts address this terminology, and how should we define medical necessity in a changing delivery system?
ISSN:0278-2715
1544-5208
DOI:10.1377/hlthaff.14.4.180