Myth: Any physician is allowed to determine if medical criteria was met to establish medical necessity.
Fact: A physician or appropriate health care professional with sufficient medical expertise is allowed to determine if medical criteria was met to establish medical necessity.
Under MAOs 42 CFR §422.566 (d):
(d) Who must review organization determinations. If the MA organization expects to issue a partially or fully adverse medical necessity (or any substantively equivalent term used to describe the concept of medical necessity) decision based on the initial review of the request, the organization determination must be reviewed by a physician or other appropriate health care professional with sufficient medical and other expertise including knowledge of Medicare coverage criteria, before the MA organization issues the organization determination decision. The physician or other health care professional must have a current and unrestricted license to practice within the scope of his or her profession in a State, Territory, Commonwealth of the United States (that is, Puerto Rico), or the District of Columbia. (Emphasis added.)
Kennedy Krieger Institute: A Medical Necessity Case Study
A five year old patient seeking treatment of their spinal cord injury and paralysis due to Transverse Myelitis (TM). The health plan requested an inpatient rehabilitation facility stay at Kennedy Krieger Institute (KKI). However, their health plan denied the request because “it did not meet the medical criteria required to establish medical necessity.”
RevAssurance Denial Topic Encyclopedia
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