Some express cynicism about the explanations given by care managers for medical necessity determinations, seeing them as disingenuous and just a disguise for an economic decision that managed care will not pay (Walter, 1995).
Practitioners note that medical necessity determinations are often inconsistent, which raises questions of reliability and validity.
Consumer advocates had long endorsed the concept of independent review organizations to which patients could appeal their MCO's medical necessity determinations as a way of ensuring the scientific basis of such determinations.
56) For many patients' rights advocates, external review for MCO adverse medical necessity determinations held promise for both preserving access to treatment in the medical marketplace(57) and eliminating the perceived implicit financial bias in MCO medical necessity decisionmaking.
In an effort to circumvent this hazard, they conceived of an MCO enrollee's right to appeal adverse medical necessity determinations to independent bodies.
For example, participants in a recent Stanford study of coverage decisionmaking in California, for which I served as a consultant, unanimously and unquestioningly supported the consensual development of "best practices" for medical necessity determinations.
69) In Pegram, the Court justified its holding--that "mixed eligibility-treatment decisions" (possibly including medical necessity determinations, but not specific, explicit contractual exclusions) do not implicate ERISA's fiduciary duties--partly on the grounds that cases involving those decisions should be heard in state court.
138) Currently, medical necessity determinations are framed in adversarial terms, which leads the public to assume that all participants are aligned on a partisan basis with one side or the other, and to expect a final decision to be rendered by a scrupulously neutral party.
On the other hand, cost considerations remain covert in medical necessity determinations
, rather than being exposed to public scrutiny or contractual specification.
It allows a provider or a provider organization to coordinate patient treatment, monitor quality of care, minimize inappropriate use of services, track utilization patterns of providers, and make medical necessity determinations
for purposes of claims payment.
There should be specific language in insurance contracts and ERISA plans regarding the employer's right and intention (and that of any agent of the employer) to make medical necessity determinations
in connection with payment of claims.