Which party typically makes the decision if a patient fits the criteria for medical necessity?

The health insurance company typically makes the decision regarding whether a patient meets the criteria for medical necessity. This determination is crucial because it directly affects the coverage and reimbursement for the services or procedures that a provider plans to deliver to a patient.

Health insurance companies establish specific medical necessity criteria outlined in their policies, which are usually based on clinical guidelines, evidence-based practices, and regulations. When a healthcare provider submits a request for prior authorization, the insurance company conducts a review based on its established criteria; this involves analyzing the patient's medical history, the proposed treatment, and how it aligns with the insurance policy guidelines.

While the ordering physician plays a critical role in advocating for the patient's care and documenting medical necessity according to clinical standards, the final decision rests with the insurer, who must ensure that any proposed procedure or treatment is justified according to their policies. Therefore, while several parties might be involved in the process, including the patient and potentially a medical review board, it is ultimately the health insurance company that holds the authority to approve or deny the request based on their criteria for medical necessity.