Nathan is a 13-year old boy who was born with cleft palate and underwent reconstructive surgery on the palate and lip as a young child. Although the functional result was satisfactory, the scar on his lip was unsightly. His parents took him to a plastic surgeon who requested preauthorization from the health plan for a scar revision to create a more normal appearance. Would the family's health plan consider the surgery to be medically necessary?
Medical necessity is a legal term used in most commercial health plan contracts to establish which interventions a health plan will cover for its members. At the same time, physicians think of medical necessity as the criterion by which they judge an intervention to be appropriate.
When used in a contract, the medical necessity standard may exclude some interventions that a physician may consider appropriate for a patient, such as treatments intended primarily to improve appearance. This is frustrating for physicians who feel obligated to do everything possible to help their patients, including correcting cosmetic defects.
The definitions and applications of medical necessity may vary considerably among health plans. While one plan might consider an intervention medically necessary if it is effective in improving health outcomes as determined by scientific evidence, another might require only that an intervention be in accordance with prevailing community standards. Contracts may further limit the range of "medically necessary" services by excluding from coverage certain interventions or entire categories of service, such as cosmetic surgery.
Health plans further specify medical necessity parameters by issuing detailed coverage policies about particular conditions. These may provide for exceptions to excluded services, based on the severity and morbidity of the condition. Even when contracts and guidelines are consistent, they can result in different interpretations for different patients, due to the subjective nature of clinical decision making.
Cleft lip and cleft palate are some of the most common structural birth defects, with an incidence of approximately 1 in 700 live births.1 Like other conditions that have both functional and cosmetic dimensions, its treatment often falls into the gray area between reconstructive and cosmetic surgery. As a result, medical necessity determinations involving this condition have proven to be especially problematic.
Given the particular circumstances described in the case above, a health plan might deny authorization for this intervention because there is no functional defect involved. Alternatively, the plan could consider the scar to be a complication of the earlier operation, in which case additional surgery would be considered to be medically necessary. Ultimately, the decision might depend on the specifics of the plan's coverage policy and on the degree of the deformity.
Suppose that the unsightly scar resulted in frequent teasing by the child's schoolmates, leading to problems with learning and socialization. Many medical directors might consider the intervention to be medically necessary under these circumstances, due to the potential psychological damage associated with the condition.2 In addition, a medical director might foresee the ability to avoid future and possibly expensive mental health services, and would authorize the intervention on economic more than medical grounds.
Now suppose that Nathan has already had several procedures to repair the scarring, but that the appearance of his lip is still not normal. At this point his plastic surgeon doubts the benefit of additional surgery. While many medical directors would deny coverage for further intervention under these circumstances, the patient's family might continue to believe that another intervention is medically necessary. These situations, in which different perceptions of medical necessity are pitted against each other, are uncomfortable for physicians and patients, yet are quite common in practice.
Recently, many plans have made efforts to draw clearer distinctions between cosmetic and therapeutic procedures by addressing, in contract language, the issue of what constitutes restoration to "normal appearance." In addition, at least 8 states now require health plans to provide coverage for the treatment and correction of cleft lip and cleft palate, although generally only "if medically necessary."3
The example of medically necessary treatment for cleft palate suggests several important points. First, medical necessity can mean different things to different people and organizations. Second, by contract, most health plans agree to pay for those interventions that its medical directors, not the treating physician, determine to be medically necessary.4
When a case falls in a gray area, knowledge of the particular definition used in a plan, as well as the process used to make the decision, can be important for a physician who wishes to provide the patient with the best possible care. While the language of medical necessity will always allow room for interpretation, physicians can best serve their patients by providing clear information to the health plan.
Singer S, Bergthold L. Cosmetic vs Reconstructive Surgery for Cleft Palate: A Window Into the Medical Necessity Debate. JAMA. 2001;286(17):2162. doi:10.1001/jama.286.17.2162-JMS1107-6-1