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Insurance and "Medical Necessity"
Chart & Stethoscope

Private Insurances follow very specific criteria to determine what should be reimbursed or payed for regarding your plan's benefits. If you want your insurance to pay for the treatment, you are required to comply with their protocols and requirements. Most important, is looking at how they define "Medical Necessity" for treatment, because this is a quick way to determine if they will accept your claim. The way an insurance company defines medically necessary conditions may differ from company to company and might not include your personal experience of your condition at all. This is because it often relates to what the company deems "curable" and whether or not functional progress can be measured and documented.

The following is an example of such a definition from Premera Blue Cross:

"'Medically Necessary' includes all of the following four parts:

  1. Most doctors agree that the treatment is useful and helps people. They use the treatment for their patients. The treatment is taught in medical schools. Doctors recognized as experts by other doctors recommend the service.

  2. Most doctors say this is the right or best treatment for a specific disease or problem. Medical schools and experts agree that this is a good treatment for the problem.

  3. The service is not just for the convenience of the doctor, the patient or the family.

  4. The service does not cost far more than a treatment that is just as likely to work

    for the problem.

'Medically necessary' does not mean that a doctor recommended the treatment... Medically necessary treatments have to meet all of the points above to be covered by the plan."

What This Means for You

What this means is that the definition of what is "medically necessary" can change based on the research to date. This can be both beneficial and also frustrating, depending on who is needing massage, and what is known about their condition.

If you have additional questions, please email me.

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