Let’s Talk About The Phrase “Medically Necessary”

Often when someone contacts me for a psychological evaluation, their health insurance requires me to request authorization before starting testing. The reason the insurance companies give is that they want to make sure that the evaluation is “medically necessary” before agreeing to pay for it.

But what exactly does it mean for testing to be “medically necessary”? Will you drop dead if you don’t get an evaluation? Probably not, but an accurate diagnosis informs an effective treatment plan. Here are some reasons (with small details changed to ensure privacy) that insurance companies have tried to deny testing:

1. “You already know they have anxiety, so why do you need to test for ADHD?” Um, because many people have both? And because anxiety treatment will not be effective if the anxiety is compensating for ADHD? Imagine telling someone they don’t need to be tested for a medical disease because they already have another medical disease.
2. “We don’t think it’s necessary to know if they have a learning disorder.” Why not? It’s impacting their functioning, and they want to know.
3. “Autism isn’t curable so we don’t cover testing for it.” I hope I don’t need to explain why this is an awful statement. By the way, check out the Autism Self-Advocacy Network to see how you can support your autistic loved ones!
4. “PTSD is not a biological condition, so we don’t cover it.” This is basically the opposite of refusing to cover a pre-existing condition: refusing to cover a condition that you were not born with. Essentially, your insurance company uses this double-talk to just not cover anything ever.

“Medically necessary” means “We won’t cover things we don’t want to pay for.” It is just vague enough for insurance companies to pad their pockets with your premium without actually having to cover your expenses.

Whether or not testing is necessary is a decision for the client (or client’s legal guardian(s) when applicable). It is a decision for them to make with the guidance and advice of the licensed, qualified professionals on their treatment team. Insurance execs who profit from denying claims and who do not have the training to understand these evaluations have no place deciding who needs testing.

My point is, call your reps. Demand healthcare reform. And if you feel like more clarity about your mental health would help you, see what your options are for an evaluation. You deserve the best care, based on your needs and not arbitrary insurance denials.