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"Not Medically Necessary": Helping America's Health Insurers Deny Coverage

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Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#191

Post by rcbdev »

nradov wrote: post #45
zardo wrote: post #12

Earlier quoted context omitted.

I feel like this should really be something people should lose their license over. By deeming something not medically necessary they are (in my opinion) effectively practicing medicine. If they aren't qualified to practice that specialty, or aren't acting in the patients interest we should really be getting malpractice suits on them and stripping medical licenses.

Legally speaking the health plan employee isn't practicing medicine in that circumstance. The requesting provider is still free to treat the patient, they just won't be reimbursed by the health plan. The requesting provider can do it for free, or the patient can pay cash. I do understand that those aren't realistic options in most cases, I'm just explaining the legal distinction.

Sounds like a massive gap in the legislature. Someone should fix this loophole.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#192

Post by roenxi »

ceejayoz wrote: post #85
roenxi wrote: post #78

Earlier quoted context omitted.

If "convenient lawcraft" is the new slang for "words have meanings" then absolutely. Insurance company employees talking about insurance is practising insurance. Nobody wants them to practice medicine, the question is whether they are they going to hand over the money or not. Money is not a form of medicine, even if the person deciding where it gets sent is medically qualified. Although on the words having meanings f…

“X is or is not medically necessary” seems like a decision a medical professional should determine, no? Subject to licensing and liability? If I build you a house and tell you the roof trusses aren’t necessary, you’d be pretty peeved.

But you didn't build my house, and if I literally get angry with you because I think you should abandon your legal shenanigans, admit to being a builder and take on legal liability for the flaws in my house that would confuse you because you are, in fact, probably not a builder and certainly not the person who built my house.

The issue with teeray's original comment is that they are saying someone who isn't practising medicine should be considered to be a medical practitioner. In fact, in this context, teeray is annoyed with them specifically because they didn't practice anything. Your analogy became irrelevant the moment it involved you doing anything.

> “X is or is not medically necessary” seems like a decision a medical professional should determine, no?

No, that is ridiculous. If I think I need to go to a hospital I'm going to go to the hospital. I don't need qualifications to work out something is medically necessary. I'm unlikely to be involved with the medical industry at all unless I've already personally determined it is medically necessary that I consult a doctor.

As a rule of thumb, patients have the final word on what they actually consider necessary. Literally anyone can have an opinion on the subject. Like, for example, an insurance worker. If the patient or the doctor is of a different opinion then they can go pay for the work themselves. It isn't that uncommon to have to go through 3 or 4 medical professionals to find one who agrees that work is necessary; I have a cancer story like that in my family.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#193

Post by jjav »

roenxi wrote: post #78
teeray wrote: post #70

Earlier quoted context omitted.

> Legally speaking the health plan employee isn't practicing medicine in that circumstance Feels like convenient lawcraft to wash the health plan employee’s hands of liability. I’m sure the prevailing popular opinion would be that this is practicing medicine.

If "convenient lawcraft" is the new slang for "words have meanings" then absolutely. Insurance company employees talking about insurance is practising insurance. Nobody wants them to practice medicine, the question is whether they are they going to hand over the money or not. Money is not a form of medicine, even if the person deciding where it gets sent is medically qualified. Although on the words having meanings f…

> Nobody wants them to practice medicine, the question is whether they are they going to hand over the money or not.

This doesn't make any sense. They're not handing over money for fun, they are supposed to pay for the medical services the insurance is supposed to cover. And the only person qualified to decide if that medical service is appropriate is a doctor who specializes in the field of that specific area.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#194

Post by ahepp »

JohnMakin wrote: post #68

I am perplexed by the type of people that are able to stomach working in these kind of positions - how do they rationalize it? Do they really just not care? Like, in some industries that are not doing great things, or bordering on evil things, I can see sometimes how one could convince themselves they were actually doing good. But this denial stuff is nearly like, "press this button to make money, knowing you may be…

What are you saying here? Do you just think it's unnecessary to audit the way 18% of US GDP is being spent? You think there is no waste, or it's so small to be negligible? Despite the fact that it's well established the US spends more and gets less benefit?

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#195

Post by ceejayoz »

tt24 wrote: post #181
ceejayoz wrote: post #138

Earlier quoted context omitted.

> I didn’t say obesity, I said unhealthy eating. Those aren’t the same thing. Australians eat a substantially similar diet to Americans, and have similar health issues (obesity, heart disease, etc.) as a result. They are deeply related things. > I straight up don’t believe the drug use one, we have way more fentalyl deaths than you and it’s not even close. Gee, I wonder if not having healthcare (including access to t…

> Australians eat a substantially similar diet to Americans Sorry I don't believe this > Gee, I wonder if not having healthcare (including access to things like therapy and rehab) might drive up drug death rates Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it > Sure; you didn't address how it's responsible for 3x the healthcare costs. Gunshot wounds obviously, we have wa…

> Sorry I don't believe this

Facts don’t require your belief. 30s in an Australian grocery store will have you feeling quite at home.

> Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it

Read again. You cited their deaths, not their drug use. Australia has plenty of drug users!

> Gunshot wounds obviously

You think the US spends 2/3 of its healthcare spend on gunshot wounds, accounting for the difference?

To quote you, “sorry, I don’t believe that”.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#196

Post by ceejayoz »

ahepp wrote: post #160

I understand that nobody likes to talk about setting this threshold, but it's not some kind of unique feature of the American healthcare system. I think the article raised some reasonable concerns about EviCore, but it would be a lot stronger if it did more to contextualize denials in terms of the other quadrants (correct approval, correct denial, incorrect approval, incorrect denial). It would also be interesting to…

The threshold is not unique.

Having several layers of private, for-profit companies incentivized to deny deciding that threshold is fairly unique.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#197

Post by ceejayoz »

bparsons wrote: post #150

Thought I would remind people here of this simple, but mostly unknown fact about American healthcare: American taxpayers invest more public dollars per capita in healthcare than anyone in the world. This before a single cent is paid into the private insurance system. Through Medicare, Medicaid, VA and other public health programs, you pay about 40% more public dollars per-capita than the most socialist, gold plated s…

Exactly. In chart form:

https://commons.wikimedia.org/wiki/File:OECD_health_expendit...

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#198

Post by tt24 »

ceejayoz wrote: post #195
tt24 wrote: post #181

Earlier quoted context omitted.

> Australians eat a substantially similar diet to Americans Sorry I don't believe this > Gee, I wonder if not having healthcare (including access to things like therapy and rehab) might drive up drug death rates Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it > Sure; you didn't address how it's responsible for 3x the healthcare costs. Gunshot wounds obviously, we have wa…

> Sorry I don't believe this Facts don’t require your belief. 30s in an Australian grocery store will have you feeling quite at home. > Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it Read again. You cited their deaths , not their drug use. Australia has plenty of drug users! > Gunshot wounds obviously You think the US spends 2/3 of its healthcare spend on gunshot wounds…

Feel free to cite something that proves that Australian diets are similar to American diets. I don’t believe claims made without evidence.

Deaths are pretty much 1:1 with drug use. Us having more fentanyl deaths mean we have more fentanyl users. Feel free to cite something that proves that Australia has the same amount of drug users as the United States.

It’s a contributing factor. Americans consume healthcare at much higher rates for many reasons, some of which I listed above. I’d fully expect Americans to pay more when they consume more.

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#199

Post by ceejayoz »

tt24 wrote: post #198
ceejayoz wrote: post #195

Earlier quoted context omitted.

> Sorry I don't believe this Facts don’t require your belief. 30s in an Australian grocery store will have you feeling quite at home. > Lol, yeah that's why we have so many fentanyl addicts, the lack of therapy, I'm sure that's it Read again. You cited their deaths , not their drug use. Australia has plenty of drug users! > Gunshot wounds obviously You think the US spends 2/3 of its healthcare spend on gunshot wounds…

Feel free to cite something that proves that Australian diets are similar to American diets. I don’t believe claims made without evidence. Deaths are pretty much 1:1 with drug use. Us having more fentanyl deaths mean we have more fentanyl users. Feel free to cite something that proves that Australia has the same amount of drug users as the United States. It’s a contributing factor. Americans consume healthcare at muc…

> Feel free to cite something that proves that Australian diets are similar to American diets. I don’t believe claims made without evidence.

https://www.abc.net.au/news/2010-04-14/australian-diet-worse...

https://www.nationalhogfarmer.com/market-news/study-finds-am...

https://www.youtube.com/watch?v=omT2ENVQziM

https://www.theguardian.com/australia-news/2025/nov/19/austr...

> I don’t believe claims made without evidence.

You're certainly making a few of them!

> Feel free to cite something that proves that Australia has the same amount of drug users as the United States.

https://www.aihw.gov.au/reports/illicit-use-of-drugs/illicit...

"According to the 2022–2023 National Drug Strategy Household Survey (NDSHS), an estimated 10.2 million (47%) people aged 14 and over in Australia had illicitly used a drug at some point in their lifetime (including the non-medical use of pharmaceuticals), and an estimated 3.9 million (18%) had used an illicit drug in the previous 12 months."

https://drugabusestatistics.org/

"Among Americans aged 12 years and older… 70.5 million or 24.9% of people 12 and over have used illegal drugs or misused prescription drugs within the last year."

That's broadly quite similar.

> Deaths are pretty much 1:1 with drug use.

You can absolutely reduce drug death rates with safe injection sites, needle programs, narcan distribution, safety education, substance abuse treatment, etc.

> Americans consume healthcare at much higher rates for many reasons, some of which I listed above.

Americans pay substantially more money for the same procedures and medications. Again: THE EXACT SAME THING; no difference in amount or quality consumed, just drastically more money going into corporate pockets.

https://nypost.com/2025/08/07/world-news/doctor-exposes-shoc...

"Atorvastatin, a medication to lower cholesterol and prevent cardiovascular disease, is priced as little as A$6.70 for 30 tablets in Australia, compared to US$2,628 for Americans."

"However, the biggest shock was Sofosbuvir, which treats hepatitis C, with a 12-week treatment roughly costing an eyewatering US$84,000 without insurance and discounts. Meanwhile, it costs about $31 for a packet of 28 in Australia on the Pharmaceutical Benefits Scheme (PBS)."

Re: "Not Medically Necessary": Helping America's Health Insurers Deny Coverage

#200

Post by missedthecue »

nradov wrote: post #186
missedthecue wrote: post #146

Earlier quoted context omitted.

Well the only ways to make any sort of insurance pool (whether it's run by the government or a private organization, for or non profit) more efficient is to deny more payouts or aggressively select for a less risky risk-pool. Medicare insures everyone over age 65, so the second option doesn't work. You can't just leave half the elderly uninsured because they're fat and likely to run up $100,000 in knee replacements.…

It's not that simple. Something like a quarter of all healthcare procedures aren't justified on an evidence-based medicine basis and do nothing to improve patient outcomes. Higher quality care actually costs less . But there's a huge amount of waste and mismanagement at all levels of the system.

I agree and making insurance more efficient involves aggressively policing that activity and denying associated claims.
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