What is Medical Necessity and why do I care?

Medical necessity is a term used by insurance companies to determine if a client needs services, and what services are appropriate. If a client “meets medical necessity” then services are approved! If not, you get that dreaded denial letter. Each insurance company has their own definition of medical necessity, but there are usually three main components:

  • Diagnosis
  • Impairment
  • Treatment Plan

Diagnosis- Most insurance companies want to see a DSM diagnosis for clients to quality for treatment. It is not enough to randomly list a diagnosis (and also not ethical). You need to identify the client’s symptoms to show they meet the DSM criteria.

Impairment- People can live with a diagnosis and not really have an impairment. But, when symptoms start affecting a person’s work or personal life, they need treatment. An impairment is an area of life that is negatively impacted by the client’s diagnosis. Example: The client is depressed and has low motivation and difficulty concentrating which impacts their ability to complete tasks at work and they are now on probation.

Treatment Plan- We’ve identified that the client needs help. Now, what are we going to do about it? It’s the therapist’s job to show the client and the insurance company how they plan to help. Will you introduce certain topics or coping skills, will you use an evidence-based practice, etc. Check with the client’s insurance company, because you may need to identify how many sessions you think this will take.

Medical necessity is a great way to conceptualize your client’s needs and how you can use your expertise to help. If you’re billing to an insurance company, it’s a requirement. If you still need help, sign up for Maelisa’s newsletter and check out QA Prep’s Facebook page for more helpful tips.