Medical necessity

What does Medical necessity mean on a medical bill?

Medical necessity is the test a plan applies when deciding whether to pay: did the care meet the plan's written criteria for your situation. A denial on these grounds is not a statement that your care was wrong or that your doctor made a mistake — it means the plan's reviewer, reading a file, did not find what the criteria asked for. That makes it one of the more appealable denials, because the fix is usually records and a letter that connect your case to the criteria the plan used.

What should I watch out for with Medical necessity?

• A denial on these grounds — ask your plan for the exact policy or criteria it applied
• Ask your doctor for a letter tying your records to those criteria before filing the appeal
• A notice you signed at check-in shifting cost to you — check which service it named and when you signed it