Unhealthy Determinations: Controlling Medical Necessity

The notion of medical necessity has been the operative tool through which healthcare coverage determinations in the United States have been rendered and justified. Now, for most people, decisions about coverage translate into decisions about healthcare since few people can afford to pay for their own healthcare. The notion of medical necessity constitutes a necessary component of any healthcare system that is committed to providing high-quality healthcare at a sustainable cost. In practice, however, reliance on medical necessity to determine healthcare coverage is only as productive as the larger health care system within which medical necessity determinations occur. Definitions of both medical and necessity are flexible and interpretations are varied. As a result, the value of medical necessity determinations depends on the character of a nation\u27s healthcare delivery and payment structure and on the identity of those rendering medical necessity determinations