The Definition of Medical Necessity

Posted by Anthony Lee Feb 14, 2009

It's natural to expect a certain treatment when you think it will help you. However, what happens when the doctor disagrees?

Consider the following example. A patient with obesity wants weight loss (bariatric surgery). However, because the patient can still losee some weight by other means, such as dieting and behavioral change, the surgeon feels the surgery is not necessary, even if the patient insists.

What does it mean for a treatment to be medically necessary? Usually, it means that the treatment can and will likely resolve the problem significantly when a less costly option can do the same. In the above example, bariatric surgery is not medically necessary because lifestyle modifications can still help the patient.

The lesson here is not to assume that specific treatments are always necessary. If you have a question about medical necessity, discuss it with your doctor who can weigh the risks and benefits.