What’s the difference between medical necessity and a covered benefit?

Why a doctor-prescribed service or device isn’t always covered by health insurance

Medical necessity and covered benefits are two entirely different things. A medical necessity is something that your doctor has decided is necessary. A covered benefit is something that your health plan or policy has agreed to cover. The fact that a doctor may prescribe, order, recommend, or approve a service does not always mean it will be paid as a covered benefit under your health plan.

My doctor says a certain service is necessary; so why isn’t it covered?

Like most health insurance companies, Blue Cross and Blue Shield of Kansas has a detailed process to help determine what tests, drugs and services are covered. (See Part 1: How we make medical policy and member benefit decisions). In general, we cover services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Our medical policy is not a guarantee that every service is covered by your health plan. It may mean that the test, drug, or service you need isn’t covered by your health plan.

What types of services may be recommended by my doctor, but not covered under my health plan?

Many experimental or investigational technologies are not typically covered under your health plan. They may not be proven effective, and may, in fact, be harmful. For example, bariatric surgery is usually not a covered service for Blue Cross and Blue Shield of Kansas members. That’s because there is not enough medical evidence to support long-term outcomes for this procedure.

Lumbar spinal fusion is another example of surgery that is not covered in most of our policies. In this case, several, less intrusive procedures or protocols may need to be met before surgery is an option.

Why do I have to “fail” other options of treatment before the one I desire is covered?

Health care can be quite complex, but there is one rule that is easy to understand: The more paid out in claims, the more premium dollars are needed. At Blue Cross and Blue Shield of Kansas, we do everything we can to keep the overall cost of premiums affordable for our members. But this isn’t possible if we cover the most expensive surgeries or procedures when less expensive treatment plans with more successful outcomes are available. We have a responsibility to all our members to spend their premium dollars wisely. Sometimes, simple lifestyle changes lead to better health outcomes than invasive surgeries.

What are my options if a service or procedure is denied?

If you don’t agree with a decision about your medical care, follow this link to the Claim Appeal Rights and Appeal form and follow the instructions.

Here are few other things you can do:

  • Take time to understand your insurance coverage. Learning how to use your health plan can help you avoid unexpected bills.
  • Understand what is covered and what is not covered by your health plan. It’s better to know what your insurance company will pay for before you receive a service, get tested, or fill a prescription.
  • If you have questions about your coverage, call customer service and talk to representative.

4 thoughts on “What’s the difference between medical necessity and a covered benefit?

  1. Tammy, called her doctor to have her blood pressure medicine refilled the doctor wanted a cbc blood work done before refilling, which she did she had met her deductible it came back not covered she was wondering why not, her coverage now says Blue Cross Gold SG what does that mean.

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