Medical Necessity?


Cardiology Care and Medical Necessity

I have been providing cardiology care for patients for years.  Today was an example of how challenging providing high quality cardiology care has become. I sent a patient for emergency open heart surgery today.   He should have gone last week.  Why didn’t he?  “Medical necessity” is why.   When I saw him in the office it was clear he was having classic angina related to coronary atherosclerosis.  I have 40 years of experience in diagnosing this. In days past, I would have set him up for a cardiac catheterization the next morning.  But insurance did not deem it “medically necessary” since he had not yet had a stress test.  To avoid him being stuck with a large unpaid bill, we set him up for a stress test.  Of course, that had to have prior insurance authorization as well, taking another few days.  After that, we had to wait for an opening in the stress testing schedule.  All told, it would be three weeks before he could have a stress test to prove that he needed a heart catheterization. 

Yesterday, he called my office to report that he was running out of nitroglycerine since he was using up to 10/day and unable to do anything without chest pain.  I abandoned my patience with the insurance company and had him come to the emergency room for admission.  On arrival he already had elevated heart enzymes and then required a nitroglycerine drip for pain control.  At his catheterization today he had severe left main coronary disease.  Fortunately, he remained stable and I was able to have a cardiology colleague set him up for emergent open heart surgery. Now it really was medically necessary!

I am aware that a tiny percentage of providers have abused the insurance system, but I am confident that we spend far more on insurance authorization than was ever spent on unnecessary claims!  How have we allowed an insurance “reviewer” working off a checklist dictate what our patients need?  How is it that their “approval” has more weight than my 40 years of cardiology training and experience?  What happened to trust that we will do the right thing?  Thankfully my patient did not literally drop dead at home.  But I have to wonder how many others actually did while waiting for “medical necessity” clearance.

heathcare education, Healing the System: A Prescription for Rejuvenating the Hearts of Healthcare Providers, healthcare consultants, Dr. John McB. Hodgson

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