Ama Policy

Medical Necessity Determinations H-320.995

U.R. Criteria

(1) Our AMA urges:

(a) health insurance carriers and government health care financing agencies to rely on appropriate medical peer review programs for adjudication and resolution of all matters concerning quality or utilization of medical services requiring professional judgment, and

(b) that peer review programs have as their goal both improved quality of care and more efficient delivery of medical service.

(2) Our AMA urges health insurance carriers, government financing agencies, physicians and medical societies to explore ways of improving communications, such as the following:

(a) In furtherance of past Association recommendations that policyholders be thoroughly and clearly informed as to the extent of their coverage, more detailed information explaining the “medical necessity” exclusion should be provided, especially when the exclusion refers more to the site of the service than to the service itself.

(b) Insurers should develop formal protocols as to their methodology for determining “medical necessity,” including distinctions between those instances where in-house medical expertise is considered sufficient and those where outside consultation is considered necessary;

(c) Third party methodologies for determining “medical necessity” should be made available to medical societies and to individual physicians, as well as listings of those specific situations (such as the ordering of either experimental or outdated procedures or questionable hospital admissions) where additional data may be required;

(d) In “medical necessity” decisions where the determination may be modified by additional medical evidence, there should be an opportunity for the treating physician to provide such evidence before a final decision not to pay is made.

Policy Timeline

CMS Rep. L, A-80 Reaffirmed: CLRPD Rep. B, I-90 Reaffirmed: Sunset Report, I-00 Reaffirmation and Reaffirmed: Sub. Res. 713, A-01 Reaffirmed: CMS Rep. 7, A-11 Reaffirmation: A-18 Reaffirmation: A-22