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.