Learn why insurance companies can deny diagnostic and preventative care claims based on whether they think the procedures were “medically necessary.”

How can I tell if my preventative procedure is medically necessary and covered by my insurance?

 

A:

When you're injured and in pain, everything your doctor recommends for treatment is going to seem necessary. He's a professional and his job is to do everything he can to heal your wounds and stop the pain. However, just because the doctor prescribes a treatment, doesn't mean it is completely necessary in the eyes of your insurance company. In fact, there is a fine line between “necessary” and “elective” care, especially when it comes to diagnostic and preventative procedures. In other words, the line that separates a necessary treatment from an elective procedure can make a big difference in determining the outcome of an insurance claim or dispute.

Preventative and Diagnostic Care: Necessary vs. Elective

Medicare and other insurance companies will only cover services that they view as being “medically necessary” and are proven to help diagnose or treat your specific condition. Unfortunately, your insurance company would rather protect its bottom line than give you the benefit of the doubt. As a result, it may justify denying your claim based upon the fact that your treatment wasn’t 100% essential. This is why it’s extremely important to understand what services are considered "elective" by your insurance provider. The following is an explanation of what constitutes diagnostic and preventative care: 

  • Diagnostic care.  Diagnostic care refers to treatment and services directly associated with a current or on-going injury or condition. This type of care involves investigating existing problems, monitoring new symptoms, and following up on abnormal test results, without having a clear answer to what is causing the problem. Depending on your specific situation, expensive procedures such as MRIs, ultrasounds, and exploratory surgery may not be covered if the issue has not been fully diagnosed. For instance, a colonoscopy may not be covered if less expensive alternatives haven’t been explored to address an issue of rectal bleeding.
  • Preventive care. Preventative care refers to any treatment or procedure that is intended to ward off further injury or counteract an illness before symptoms manifest or evolve into a severe condition. Preventative care can range from immunizations and blood screenings to routine mammograms for women over 40. Authorized preventive care procedures can help save your life by detecting problems while they’re manageable and before they get out of control. The majority of preventive services are included in most insurance policy’s “medically necessary” coverage clauses. However, before receiving any treatment, you should always verify your policy’s guidelines to ensure that you won’t get stuck with the bill.

For more information on insurance rights and injury compensation, take a few moments to browse our extensive collection of Blogs, FAQs, and informative articles. You can learn a lot about your rights and how to successfully pursue an insurance claim. Contacting the Andrew Kim Law Firm, PLLC, directly can also help you better understand your coverage and right to compensation. Before speaking to an insurance company or settling on a claim, call our office today to ensure your future is protected.