Getting Approval for Medicaid Services: Medical Necessity

State Medicaid programs can deny coverage for a particular treatment if the treatment is not medically necessary. Each state has defined the term "medical necessity" differently in their laws and regulations; the federal Medicaid Act doesn't have a definition of medical necessity. Below we'll discuss how some states define medical necessity, but ultimately, your treating physician's opinion about whether a particular treatment is medically necessary will be the most important factor in getting Medicaid to pay for the treatment.

What Is Medical Necessity?

No state has a definition of medical necessity that says a treatment is medically necessary just because a doctor says it is. All states have some other constraints built into their definitions of medical necessity. Many states have cost restrictions built into their definitions, in an effort to reduce their Medicaid costs by limiting patients to the least expensive treatment. For example, Florida limits patients to the least expensive treatment that is effective. Other common restrictions on states' definitions of medical necessity are prohibitions against experimental treatments, requirements that the treatment provide a significant benefit to the patient, and requirements that the treatment not be provided primarily for the patient's or doctor's convenience.

Other states define medical necessity more broadly, giving the opinion of the treating physician more weight. For example, California's Medi-Cal program defines a treatment as medically necessary simply when it is reasonable and necessary to prevent significant illness or disability, relieve severe pain, or save someone's life.

Medical Necessity and Children

Medicaid has a program called EPSDT (Early Periodic Screening, Diagnosis, and Treatment) for children under the age of 21. States must offer all of the Medicaid mandatory and optional services and treatments to children, even though they might have decided to exclude some optional services for adults as a cost-saving measure. (See our article explaining what services Medicaid pays for.)

In addition to requiring states to cover a comprehensive list of possible treatments for children, Medicaid requires state Medicaid programs to cover any treatment that is medically necessary (according to the particular state's definition of medical necessity), regardless of whether the treatment would be available for an adult in the state. For example, a state may limit Medicaid coverage of inpatient hospital stays to 45 days for adults, but the state's Medicaid program must pay for a longer hospital stay for a child if the hospital stay meets the state's definition of medically necessary. In short, EPSDT gives children extra legal protection and may be the basis for requiring a state's Medicaid agency to fund a particular treatment.

Your Doctor's Opinion

If you have received a Medicaid denial because your state Medicaid agency thinks that your treatment is not medically necessary, you should review your records to see whether your treating physician told Medicaid that the treatment you want is medically necessary. If your doctor doesn't think the treatment is necessary, you are unlikely to get Medicaid approval for it, regardless of the state you live in. You should talk to your treating doctor to try to understand the doctor's medical opinion, and seek another doctor's opinion if you continue to disagree.

If your doctor told Medicaid that the treatment was medically necessary, but Medicaid still denied coverage, then you should look at the denial notice you received from Medicaid to see why the treatment was denied. You have the right to appeal any Medicaid decision and request a hearing on any denial of coverage. For more information, see our article on appealing a Medicaid decision.