For Providers: Appeals & Letters of Medical Necessity

Getting patients what they need:  Appeals & Letters of Medical Necessity

Learn how to appeal denials, or request prior authorization, for services you prescribe and believe are medically necessary.  Medical necessity is a legal, not a medical, definition. This section includes an explanation of medical necessity, directions for writing a letter, and a template for a letter that can be adapted for use appealing medication, equipment, or other service denials.

  • Click here for a brochure explaining how to write a letter of medical necessity.
  • Click here for a template letter of medical necessity that you can cut and paste onto letterhead.
  • Click here for a template to attach to managed care pharmacy prior authorization forms requesting non-formulary medications.

Denied services, or services requiring prior authorization, must be medically necessary. Medical necessity is a legal, not a medical, definition.

Under Pennsylvania Medical Assistance, a service is medically necessary if it meets any one of the three standards below:

  • The service or benefit will, or is reasonably expected to, prevent the onset of an illness condition, or disability
  • The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition or disability.
  • The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

How do I use this definition for a prior authorization? You can either write a letter using the above language, or use our template to request the equipment, medication, or service. If you are using a managed care medication prior authorization form, include or attach documentation with the above language to support your judgment of the necessity of the non-formulary medication. It is critical to include all relevant medical information; many denials are issued for inadequate information. Writing “service medically necessary” without supporting data will lead to denial.

What can patients or practitioners do if they disagree with an insurance decision to deny services? File an appeal.  A patient can file either a “grievance” or request a “fair hearing,” or both, depending on whether she is in Medicaid managed care or fee-for-service.

(i) In Managed Care:

Patients can either file a grievance with the plan, which is an internal review, or request a fair hearing directly from the Department of Public Welfare. Filing a grievance with the plan does not preclude later asking for a fair hearing. If the initial appeal is denied, a patient can file a second level grievance and subsequently request an independent external review.  A grievance is a request to reconsider a decision concerning medical necessity or appropriateness of a health service. If a service is approved only in part (e.g., 4 hours of skilled nursing instead of 8), that is considered a denial and may be appealed.

If a patient is receiving a service – whether it is a medication, an inpatient stay, or skilled nursing at home or in a facility – which is then denied in whole or in part, if the denial is appealed within ten days the managed care plan must continue to cover the service until the dispute is resolved.

(ii) In Fee-for-Service:

Request a fair hearing from the Department of Public Welfare.  An Administrative Law Judge will preside over the hearing, and DPW or the managed care plan will have to justify its denial of services. Participation by a treating provider is crucial in demonstrating medical necessity, and both grievances and hearings can be rescheduled according to a provider’s availability.  Practitioners can usually participate by telephone.

What if a denied service is urgent for the patient? File an expedited grievance or request for fair hearing, which must be resolved within 72 hours.  A practitioner has to be involved to file an expedited appeal.

What is my role as a physician in this procedure? If you have prescribed something for your patient which you believe is indicated, and the insurance issues a denial, the best way to help your patient is to write an excellent letter of medical necessity and to participate in the fair hearing.  The patient does not need a lawyer, but does need the physician’s help, including clear medical record notes documenting the need.

What if I don’t feel able to advise patients in this process? Grievances are part of the legal contract. This is a good time to have the patient call the Pennsylvania Health Law Project, 1-800-274-3258. Its legal advocates will be able to advise the patient and to provide representation if appropriate.

So these rules apply to commercial insurance? Pennsylvania state law requires appeal procedures for certain commercial insurances. They differ from Medical Assistance requirements. If your patient has commercial insurance and Medical Assistance, and the problem is with the coordination of these coverage types, have the patient call the Pennsylvania Health Law Project.

 

Helpline

Having trouble accessing publicly funded health care coverage or services? Call…

1-800-274-3258

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