Medical Necessity Review

Who Makes Which Decisions?

According to the National Committee for Quality Assurance (NCQA) 2019 UM standards:

A medical necessity review requires consideration of the member’s circumstances, relative to appropriate clinical criteria and organizational policies. Medical necessity reviews that result in adverse decisions (denial, modification, termination) can only be made by an appropriate clinical professional. NCQA considers the following practitioner types to be appropriate for review of the specified UM adverse decisions:

Physicians, all types: Medical, behavioral healthcare, pharmaceutical, dental, chiropractic, and vision denials.
Nurse practitioners*: Medical, behavioral healthcare, pharmaceutical, dental, chiropractic, and vision denials.
Doctoral-level clinical psychologists or certified addiction-medicine specialists: Behavioral healthcare denials.
Pharmacists: Pharmaceutical denials.
Dentists: Dental denials.
Chiropractors: Chiropractic denials.
Physical therapists: Physical therapy denials.

* In states where the organization has determined that practice acts, or regulations allow nurse practitioners may practice as independent practitioners, nurse practitioners may review requests that are within the scope of their license.

Insight

First line reviewers, such as nurses or other healthcare professionals may approve medically necessary services. They can also perform initial case reviews, document findings, and prepare case summaries for services that do not meet medical necessity guidelines. However, they cannot make final decisions, such as denials, modifications, or terminations for medically necessary requests. Depending on the organization's protocols, case finding summaries can be written and/or verbal.

Per NCQA, decisions about the following require medical necessity review:

Covered medical benefits defined by the organization’s Evidence of Coverage or Summary of Benefits.
Preexisting conditions, when the member has creditable coverage and the organization has a policy to deny preexisting care or services.
Care or services whose coverage depends on specific circumstances.
Dental surgical procedures that occur within or adjacent to the oral cavity or sinuses and are covered under the member’s medical benefits.
Out-of-network services that are only covered when medically necessary and in clinically appropriate situations.
“Experimental” or “investigational” requests, unless the organization’s policies specifically exclude the requested services or procedures from the benefits plan and deem them never medically necessary under any circumstances. In this case, medical necessity review is not required.
Prior authorizations for pharmaceuticals and pharmaceutical requests requiring prerequisite drug for a step therapy program.

Per NCQA, decisions about the following do not require medical necessity review:

Services in the member’s benefits plan that are limited by number, duration or frequency.
Extension of treatments beyond the specific limitations and restrictions imposed by the member’s benefits plan.
Care that does not depend on any circumstances.
Requests for non-medical, in-home personal care services, such as cooking, grooming, cleaning and assistance with other ADL-related activities.

Insight

Even though NCQA does not require medical necessity review for these services, there may be compelling evidence to support the medical need for exceeding limit restrictions. Thus, the request should be reviewed and, as appropriate, allowed an exception. This is especially important to Medi-Cal Managed Care members since they have limited income and may need the additional service to avoid more costly interventions. For example, a member has a benefit limit of 20 acupuncture visits/year. However, the acupuncturist is requesting 2 more visit to complete the treatment plan and to avoid ED visits and hospitalizations. As the UR nurse, you review the member’s history and indeed, confirm that prior to starting care with the acupuncturist, the member was seen in the ED 3 times and hospitalized once during the previous 6-month period. Since starting care with the acupuncturist 5 months ago, the member has not been in the ED or hospital. Given this scenario, it may be prudent to allow the 2 additional acupuncture visits.

Medical Necessity Review

Who Makes Which Decisions?

Insight

Insight

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