LAC report on medical necessity requirements for SUD treatment

Abstract

“Medical necessity” — the phrase used by payers to encompass one fact: whether they will or won't pay for treatment. Payers usually select and apply a set of “medical necessity criteria” and use that to determine whether something is reimbursable. Obviously, something experimental or proven not to work or to be harmful shouldn't be reimbursable. Generally accepted standards of care should determine medical necessity, notes a new report from the Legal Action Center (LAC) on the uses — or misuses — of medical necessity in substance use disorder (SUD) treatment. Too often, however, health plans use medical necessity criteria only to restrict care and control costs, especially in SUD treatment.