What is "Medical Necessity?"
I visited the Blue Cross / Blue Shield of Tennessee web site and
found this information:
We determine medical necessity when we do careful and thorough
research that shows whether the service is:
consistent with the symptoms or diagnosis of the subscribers
condition, disease, ailment or injury;
meeting standards of good medical practice;
not mainly for convenience instead of need;
and the most appropriate supply or level of service that
can safely be given to the subscriber.
When applied to the care of an inpatient, it also means that
the subscribers medical condition requires a hospital stay to
be sure the care is given safely.
The fact that a physician has prescribed, performed, ordered,
recommended or approved a service does not in itself make it
medically necessary and appropriate.
Importantly, we take into account not just whether a service or
drug can be considered medically necessary. We also do the
necessary research to find out if the service or drug has been
found to be medically necessary for a particular condition or
conditions, but not for others.
Policies based on science, medical professionals standards.
With our status as Tennessees leader in health care financing,
our customers count on us to make unbiased claims payment
decisions based on the most up-to-date standards of medical care.
Those standards are determined by nationally recognized sources
such as the National Institute of Health, the Centers for Disease
Control and Prevention, and the American Medical Association.
In making policy decisions about technology, BCBST uses as a
resource Internet searches and numerous organizations that
evaluate medical technology, including highly respected sources
such as Hayes and ECRI.
We also consider it very important to listen to input from
physicians and other health care providers in Tennessee in making
Experimental/Investigative aspects of care must be considered.
When a certain type of treatment or drug is being considered
for a particular condition, but the data on the effectiveness of
the treatment/drug on that condition is insufficient to determine
its value, it may be classified as Experimental or Investigative
(E/I). BCBST is careful to use a fair and thorough approach in
deciding which medical supplies and procedures should be classified
in the E/I category, as we can only responsibly provide benefits
for treatments that are not investigative.
We have numerous sources we turn to in order to make the
determination. The sources are:
--The Hayes, ECRI and similar research organizations and outlets
--The American Medical Associations Diagnostic And Therapeutic
Technology Assessment (DATTA), a consensus from a panel of
--The BlueCross and BlueShield Associations Technology Evaluation
--Peer-reviewed medical literature, and
--Contacts with network and contracted Tennessee providers.
At BlueCross BlueShield of Tennessee, we lean heavily on the
medical communitys consensus in making determinations about
"investigative" services or drugs. It is one of the ways in which
we ensure that BCBST remains sensitive to providers views on
whats best for their patients.
Technology benefit decisions result of rigorous review.
The rapid advance of modern technology and medical breakthroughs
make for a complex atmosphere for BlueCross BlueShield of Tennessee
when it must make policy on which new medical technologies to
approve for benefits. BCBST is committed to keeping its benefits up
to date with current medical practices.
Medical technology benefit issues are identified in a number of ways,
including benefit interpretations, provider concerns, marketing
considerations, financial and legal issues, and operations problems.
Also of key importance is whether a current technology is outdated
or may be used in a new way, and the importance of evolving or
When the need for a possible review of policy is identified,
a staff of licensed nurses conducts preliminary research.
A thorough review is also conducted by BCBSTs Medical Technology
Assessment Committee, looking at the issue in the context of
information from reputable technology assessment organizations,
from Medline searches and other Internet sources, and from medical
literature, journals, centers of excellence and other network
providers. From that point, the Technology Assessment committee
(made up of medical directors, network physicians and support staff)
will evaluate the executive summary and background research when
needed, apply BlueCross BlueShield Association criteria, and search
for a medical consensus.
Criteria for technology assessment approval include:
· government approval
· conclusive scientific evidence re: health outcomes
· the technology must improve outcomes
· the benefits must be equal to or greater than that of existing technology
· the results must be attainable outside of the investigational setting
Great majority of claims paid with full benefits
Think that health insurers routinely deny claims?
Not so -- at least with BlueCross BlueShield of Tennessee.
Some 93 percent of claims providers send to us are approved for full
BCBST payment (within the customers contract guidelines) on the
Of the remaining 7 percent, the huge majority qualify for some
payment toward some of the charges, and only a very small
percentage are denied any benefit payout.
Our claims payment decision-making processes and policies are
designed to make sure our customers get the care they need and
are not charged for unnecessary or unproven care.
The above was slightly long but very informative and I hope
you picked up on the part about research being made by
nurses! I wonder how many practicing physicians are involved
in the decision making process?