Medically necessary procedures

Insurers define medically necessary procedures as health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. Insurers require documentation from providers such as CPT codes and detailed medical records to approve these procedures, the Insurance Information Database reports.

Insurers deny procedures like elective cosmetic surgery because data show they are not essential to sustain life or restore function. The Centers for Medicare & Medicaid Services (CMS) classify treatments as medically necessary when peer-reviewed evidence supports their efficacy, safety, and necessity.

Insurers cover only procedures substantiated by peer-reviewed studies or standard guidelines, such as appendectomies for appendicitis and insulin therapy for type 1 diabetes. Appeals processes exist if providers believe a denial was incorrect; the National Association of Insurance Commissioners (NAIC) reports over 50% of appealed denials receive approval after further review.

Medical necessity criteria vary by insurer; Aetna may approve bariatric surgery if BMI exceeds 40, while Cigna might require additional comorbidities. Health Maintenance Organizations (HMOs) use utilization review boards to verify the appropriateness of requested procedures before authorizing payment.

Emergency room treatments qualify as medically necessary only if delaying care could cause serious harm or death, according to federal EMTALA regulations. Medicare publishes annually updated Local Coverage Determinations (LCDs), which list specific procedures deemed medically necessary per diagnosis code.

Insurance contracts specify exclusions; LASIK eye surgery appears on exclusion lists across all major U.S. Health insurers due to lack of demonstrated medical necessity for vision correction alone.