What Does “Medically Necessary” Mean?

Let’s say one of my jail patients has a moderate-sized inguinal hernia.  I want to schedule surgery to have the hernia fixed, but to do so, I have to get authorization.  This is not unusual.  Just like the outside, before I can do medical procedures or order non-formulary drugs, I must get the approval of the entity that will pay the bill.  By contract, my jails house inmates from a variety of jurisdictions, such as the Federal Marshals, ICE, the State Department of Corrections and other counties.  This process of “Utilization Management” is very similar to getting pre-authorization from an insurance company or Medicaid in the free world, probably because Corrections simply copied the outside pre-authorization process.

Having done this process hundreds of times over the years, both in the free world and in Correctional Medicine, I am struck by a phrase that keeps coming up: “medically necessary.”  When authorization for a procedure is denied, the reason often given is that it is “not medically necessary.”  I then have to argue that what I am requesting is, indeed, medically necessary.  The problem is that there are many possible definitions of “medically necessary,” and I believe many disagreements arise because two parties understand “medical necessity” differently.

“Medically necessary” might mean “necessary to sustain life.” 

In other words, without this procedure or treatment, the patient will die or is likely to die.  For example, insulin is medically necessary for Type 1 diabetics.  Without insulin, they will die.  Dialysis is medically necessary for patients with no renal function, otherwise they will die.  Chemotherapy is medically necessary for the survival of a cancer patient.  Surgery is medically necessary for a perforated bowel.  However, this definition leaves out many therapies where the benefit is harder to quantitate. 

Is insulin medically necessary for a Type 2 Diabetic? Is Flomax medically necessary for a man with urinary difficulty? Is surgical repair medically necessary for a torn rotator cuff? By this definition, probably not. This is the definition that is likely to be used when the reviewer wants to deny a claim. “necessary to sustain life” is great when you don’t want to pay for a procedure or a medication. But using this definition can reach absurdity.  I once saw a man who had been incarcerated in prison for many years prior to being transferred to my jail.  When I first examined him, I found an inguinal hernia so large that he had intestines in his volley-ball size scrotum.  I asked “Why haven’t you ever had this hernia fixed?” I asked.  “They told me it wasn’t medically necessary.” 

This is the definition that Utilization Management people have in mind when they deny treatment for Hepatitis C in patients with no evidence (yet) of liver disease.

This definition clearly is not the right one for correctional medicine.

“Medically Necessary” might mean “commonly done in the community.”

This “Community Standard” is probably the most common definition for “medically necessary” that I hear when people discuss medical treatment for inmates. It sounds good: “If a patient can get a procedure or a medicine in the community, it should also be available in a prison.” That seems to make sense. However, there are problems with this. 

The first is that what is commonly done in the community depends on the patient’s insurance status.  Take a surgical repair of a torn rotator cuff, for example.  A well insured patient will have that surgery done.  A patient with no insurance will not.  a rotator cuff repair is a surgery that hospitals and surgeons will not do without payment. They justify this by reverting to “it’s not necessary to sustain life.”

A second problem with the “Community Standard” is that many medical treatments commonly done in the community have no solid foundation in science. Many expensive medications commonly prescribed in the community are no better than less expensive generics (like just about everything in the typical sample medication cabinet). The Journal of the American Medical Association recently published a paper worth reading entitled De-adopting Low Value Care: Evidence, Eminence and Economics that advocates eliminating commonly done but low value medical care. This is also the goal of the Choosing Wisely Campaign, in which each medical specialty was asked for a list of medical tests and procedures that are commonly done in the community but should not be done.  It is fascinating to read through these. A good place to start is the Choosing Wisely recommendations of the American College of Family Physicians (found here https://www.choosingwisely.org/clinician-lists/#parentSociety=American_Academy_of_Family_Physicians).

“Community Standard” is so easy to meet that it is the definition people reach for when they want some medical procedure approved. For this very reason, the Community Standard should not be the go-to definition of “medically necessary.” It is too lax; it allows too much low value and even harmful medical care.

“Medically Necessary” might mean “accepted medical practice.”

“Accepted Medical Practice” means that the medical procedure or treatment is recommended by an up-to-date medical textbook (like Uptodate or Essential Evidence Plus) or a guideline published by a legitimate medical group (such as the US Preventative Services Task Force or the American Academy of Family Physicians). This (in my opinion) should be the standard definition of “medically necessary.” Ideally, if I want authorization for something, I should be prepared to back my request up with a credible source. If a procedure is denied, I expect the denier to be able to cite a medical source as the reason for the denial.

Of course the reality is messier than this ideal of looking everything up! One problem is that many published guidelines are not evidence-based, unduly influenced by Big Pharma, or otherwise simply crappy. A third problem is that many topics in medicine are controversial. Some good physicians will do one thing and other good physicians will do another.

Finally, the people doing the Utilization Management reviews (usually RNs) are sometimes not familiar with the medical literature. That is why many Utilization Management decisions are outsourced to proprietary “evidence-based” algorithms such as McKesson’s Interqual or the Milliman Care Guidelines.

For me, knowing the various definitions of “Medically Necessary” will help me in my quest to get surgery approved for my patient’s hernia. This surgery may not be necessary to sustain life, but it is the community standard of care (no community surgeon will every say “Nope. I don’t want to fix that.”) and surgery is the recommended treatment by medical textbooks and guidelines.

Do you have experience getting medical treatments authorized at your facility? Please comment!

As always, what I have written here is my opinion, based on my training, research and experience. I could be wrong! If you think I am wrong, please say why in comments.

3 thoughts on “What Does “Medically Necessary” Mean?

  1. The crux of this issue – to me – revolves around a number of factors and is potentially at risk of over simplification.
    Apologies for the length of this comment – these ideas are a compilation / adaptation from a number of sources.
    Medical services provide offender treatment for illness, condition or injury deemed medically necessary by health staff. Treatment is ‘Medically Necessary’ when, after clinical assessment the condition shows symptoms / signs and absence of therapy is expected to result in one or more:
    • Placing the patient or others health / life in serious jeopardy; or
    • Increasing or producing permanent impairment of bodily function; or
    • Continuing or accelerated deterioration or loss of bodily function.
    • Reasonable attempt to control bona fide pain is medically necessary.
    • Treatment is not medically necessary for stable conditions:
    • Present for a significant period of time and;
    • Not expected to deteriorate over a period of less than six months or;
    • For which the patient has not previously sought definitive treatment or;
    • The patient refused treatment, failed to be compliant with treatment.
    No Convenience, No Curiosity, No Cosmetics

    The effectiveness of a treatment is determined when linked to a specific condition or diagnosis. Every person is entitled to a diagnosis as part of the correctional health program. After the diagnosis is made, then the appropriateness of treatment to be employed is determined. The basis of the treatment utilization review process is the material published by the Oregon Health Services Commission. The commission used a combination of scientific data and social values to develop a methodology that ranks condition / treatment pairs. There are aspects of health care unique to adult correctional institutions that do not allow one-to-one correlation of the categories on the Commission list. Given those limitations; the list of categories for medical services has been established as follows:

    Medically Necessary – Acute:
    1. Acute fatal, full recovery
    2. Maternity care
    3. Acute fatal – non-full recovery

    Medically Necessary – Chronic:
    4. Chronic fatal – Improved with treatment
    5. Comfort care – hospice care and terminal pain management
    6. Dental care – determined to seriously affect health during incarceration
    7. Proven effective preventive care
    8. Acute nonfatal – full return to health
    9. Acute nonfatal – Incomplete return to health

    Medically Acceptable not Medically Necessary:
    10. Chronic nonfatal – one time treatment may be effective
    11. Chronic nonfatal – repetitive treatment may / may not be effective

    Limited or No Medical Value:
    12. Acute nonfatal – recovers without treatment
    13. Infertility services
    14. Low effectiveness preventive care
    15. Fatal or nonfatal – treatment causes minimal or no improvement
    16. Access to adequate diagnosis, by an offender, and evaluate of health care by appropriate medical staff is essential and not diminished by this policy.

    Approval for any request for ‘elective’ care will be based upon the guidelines in this policy. It is however, NOT the policy of to provide medical care that is simply a matter of convenience, curiosity, cosmetics or when not medically necessary.
    Factors evaluated during deciding regarding approval of medical therapy, particularly when the issue is in the category – Medically Acceptable not Medically Necessary, are:

    1. The global necessity of the treatment 6. Amount of incarceration remaining
    2. Urgency of the treatment needs 7. Is the condition a pre-existing issue?
    3. The conditions’ status 8. Is the condition a pre-confinement issue?
    4. Any prior response to other treatment 9. Available alternatives
    5. Risk / benefit ratio 10. Cost / benefit ratio
    11. Prior treatment compliance

    Functional Definitions

    Medically Necessary –Acute: Medically Necessary care will be routinely provided to any offender by correctional health staff. Any health service staff may authorize care and treatment at this level.

    Medically Necessary – Chronic: Medically Necessary care may be provided to offenders by correctional health staff subject to periodic utilization review by the institution Medical Officer. Any prescribing practitioner may authorize care and treatment at this level within the guidelines of utilization review.

    Medically Acceptable not Medically Necessary: Medically Acceptable care may be provided to offenders by correctional health staff subject to Authorization for care and treatment of these conditions. At this level the authorization will be determined on a case – by – case basis.
    Acute Condition / On-site Service – Authorized by Chief Medical Officer
    Chronic Condition Off-site Service – Authorized by Utilization Review
    Limited or No Medical Value: Health care and / or treatment of these conditions will not be authorized.

  2. The ontology of the term medically necessary is IMHO non existent (translation: its definition and conceptualizations are ill-defined). I prefer (and always use) the terms elective, semi-elective, or non-elective care. Non-elective treatments or procedures are by definition (and conceptualization) needed to quickly improve or preserve the quality of life or to sustain life. These treatments are emergent and necessary. Semi-elective treatments or procedures are necessary but not emergent (e.g. arthroscopic surgical treatment of severe ankle pain). Elective procedures are neither emergent nor strictly necessary (e.g. bunion surgery). Medical co-morbidities will modify what treatments or procedures fit into these 3 categories. Of course, specific cases and medical disagreements will make these ontologies open to interpretation. For example, will delaying a rotator cuff repair adversely affect the eventual clinical result (ie is it non-elective or semi-elective)? Neither community standards nor cost should matter. Evidenced based medicine (which is obviously constantly evolving) should properly inform clinical decision making, and if used judiciously will often lead to lower cost of care.

  3. When language is focused to address functional impairments and their ongoing risks and hazards the elements for a decision or judgement become clearer (and defendable when inappropriately denied).
    .
    The gentleman w/ the chronic massive (though reducible) hernia has relative necessity due to it’s size and hazard, but then this is balanced against the risk for the procedure….

    Similarly, the pretrial detainee with genotype I Hep C and low index of hepatocellular maturity has a medical “necessity” for treatment than may be deferred to future treatment in the community or following sentencing. This stands in contrast to another detainee with genotype III with advancing disease who has a far different disease and death risk within the next year.

    In this way, it may not be clearly be a difference of definitions, but how language is applied to individual cases that always differ from others on careful risk/benefit analysis

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