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How is Medical Necessity Established?

By January 1, 2015November 19th, 2020Blogs, Dr. Jenny Yip

Depending on your insurance provider, pre-approval for standard cognitive behavioral treatment isn’t necessary. However, if you are seeking an Intensive Outpatient Program (IOP), it is. One of the primary components of getting authorization for IOP treatment is showing that treatment is medically necessary. Even if your clinician has determined that an intensive level of treatment is warranted, your insurance provider must confirm that medical necessity has been proven. You can assist this process by submitting a letter with other documents needed for pre-approval.

Here are a few points to address in your letter:

  • Clearly describe the deteriorated state in which the patient is functioning. Describe the degree to which he/she is unable to perform family, school, or work activities, the specific symptoms that affect his/her life, and how family members have been impacted.
  • Give examples of how past and current events have contributed to the worsened condition of the patient and family.
  • Emphasize the family’s commitment to the treatment program. This demonstrates that the patient will have support during and after treatment, which offers a higher recovery rate and a smaller chance of relapse.
  • If the patient is experiencing thoughts of harm to themselves or to others, it is very important to note this in your letter. While it may be difficult to accept that your loved one is suffering in this way, it is a significant fact that demonstrates the severity of the matter.

Some additional tips for child patients:

  • Instead of one parent writing on behalf of the family, each parent can write his/her own letter since each has an individual relationship with the patient and his/her own personal experiences as well.
  • Ask your child’s teacher, school counselor, or coach to write a letter. These professionals may have vital information to share about your child that will support your case for medical necessity.

To find out more about medical necessity, please visit your insurance provider’s website.