Necessity vs. Appropriateness


With the insurers all in our faces, some even offering doctors gift cards if they will sign unfair contracts, I have been thinking lately about medical necessity.  This is a benchmark that case reviewers set in order to determine if a treatment should be covered by insurance and despite the appearance of objectivity, there really is none.  The question of whether or not something is medically necessary can be confusing and arbitrary. 

It is medically necessary to provide spinal manipulation for a cervicogenic (neck caused) headache?  Certainly, manipulation can help in many instances.  And, in my experience, it is among the most effective and fastest treatments for this type of headache with the least amount of side effects when performed correctly.  But is it medically necessary?

The usual course of events for a cervicogenic headache is that is may naturally reduce in, say, a week. With chiropractic manipulation the headache may diminish within only a few hours.  Does that make chiropractic manipulation medically necessary for this condition?  Certainly the patient will experience less pain by having a headache for a shorter period of time but is lessened pain by a few days a medical necessity?   By that same argument, what is truly medically necessary if it does not fall into the category of life-saving emergency care.

Perhaps the terminology needs reframing.  It is not the ‘necessity’ that should be examined but rather the appropriateness of a treatment.  For example, if a person is experiencing an episode of back pain, one could argue that chiropractic, acupuncture, medications, surgery all might not be medically necessary — but that does not exclude some or all of them from being medically appropriate.  A trip to the zoo, however, is neither medically necessary nor medically appropriate for this condition (unless the purpose is to remove a monkey from someone’s back…but that’s another blog post).  

If we change the thinking from necessity to appropriateness, we are also able to decrease paying for procedures that have been proven to be ineffective while reimbursing for those that are appropriately effective.

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