James Anderson

Unraveling the Mystery Behind "Medically Necessary"

I will say the two words I most dreaded hearing as an office manager were the terms “medically necessary”. It can be such an ambiguous term and it’s true criteria can elude even the most seasoned doctor and OM. Then the term takes on a whole new meaning when the dentist decides to begin billing to medical carriers. So let’s decode the myth and the fact behind “medically necessary” procedures.
Medical necessity procedures require predetermination. MYTH. Medical necessity and preauthorization are two different things. While a procedure may require documentation of medical necessity that does not mean that it requires preauthorization.
Dental procedures are not medically necessary. MYTH. If a dental procedure is done to treat a condition that has developed because of, been accelerated by or can be attributed to a medical condition then those procedures MAY be deemed medically necessary. A procedure being dental in nature does not automatically exclude it from being medically necessary.
The healthcare provider determines what procedures are medically necessary. FACT. A lot of us are familiar with carriers denying procedures under the guise that they are “not medically necessary”. This has led to the incorrect assumption that the carrier establishes medical necessity but it is the provider that is establishing medical necessity as they are seeing the patient. Good clinical notes and proper diagnostic procedures will establish medical necessity every single time. The majority of denials are because documentation was not adequate to support the findings.
Medically necessary procedures must be done in a hospital. MYTH. Medically necessary procedures can be done in any setting. A hospital, an office, an outpatient facility or even a mobile clinic. It is important to reference where services were performed for proper claim submission and reimbursement.
The most important part of establishing medical necessity is to document the patient’s medical history and the underlying need for the procedures being performed. Dental procedures can be medically necessary if the patient has periodontal disease aggravated by a disease (such as diabetes), needs dental implants to restore teeth due to trauma or needs more frequent cleanings due to Alzheimer’s or dementia complicating proper hygiene and personal care. When documented efficiently and substantially medical claims for dental procedures will process just as smoothly as dental claims and be a plus for both offices and patients.


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