“Medical Necessity”: 2 Cringe-Worthy Words

I have an interim case manager from my insurance company helping me while my assigned case manager is away on temporary medical leave.

But as much homework as I’ve done on trying to clarify a few benefits & find information & details in my plan (now that my listing is imminent) I’ve unfortunately been given a lot of mis-information by the agents I’ve been speaking with. Even after they’ve put me on hold to clarify with their supervisors.

As a former rep, I understand this & that people make mistakes.  I suppose I should be happy all of this is clarified now, before I would try to submit claims & have them reject. Then be irate because I thought & was told something was covered when in fact, it wasn’t.

I spent so much time the past few days on the phone going back & forth trying to clarify one simple request.

If I needed one, would I be eligible to have medical transport (like an ambulance or ambulette) take me down to my center if it was an early morning call, rush hour, or if there was some other instance where I was afraid I might cut the call window too close?

I was initially told yes, though it would considered a non-emergency.

I asked for a few names of in-network services I could call.  Of the 4 I was offered (& I confirmed were up-to-date on the provider search tool on the website), only 1 even bothered to pick up the phone.

I couldn’t even leave a message with the other 3. I let it ring at least 6-10 times each call. No voicemail, no option to leave a message, no dispatch. Nothing.

The one entity that did answer was not rude, but was not overly helpful either. Basically told me they would never guarantee a pick-up.  I could “try” calling the day I needed the transport & see if they would be “willing & available” to take me.

Considering they are at least 15 miles away & the furthest out, I thought “Thanks, but no thanks.”

I did tell this case manager that someone from the operations department might want to reach out to those listed providers & find out why they wouldn’t pick up the phone. Perhaps they went out of business?  I said that because what if was a situation where I did need transport & couldn’t obtain it & it was an emergency?  They were contracted with the carrier, that means they should at least be able to take a phone call & provide basic information.

The case manager confirmed that I didn’t have benefits for transport, period & I had been quoted incorrectly.  When I asked where in the plan it mentioned that denial, she gave me the two cringe worthy words that are part of a phrase that used to drive me crazy as an agent.

It’s not “Medically Necessary.”

I get why I don’t have benefits for this request from an insurance company perspective.   I was only upset because asked very specific questions to try to get an accurate response the first time because I wasn’t absolutely sure I had benefits in the first place. It had dawned on me that it might be denied under this clause or another.

So it irks me that even the supervisor couldn’t get it right, even after the agent did due diligence to check before she confirmed it for me.

(Then they wonder why most of the public thinks insurance carriers are liars.)

I also was told by my original case manager that I had to live within a 100-150 mile radius to qualify for the transplant housing costs for my post-transplant rehab stay at the transplant house to be covered.  I had benefits last year for that & didn’t see that restriction, but couldn’t find them listed at all this year so that’s why I asked.

I pressed for more information & a re-confirmation because I was upset that this information was not clearly outlined in my plan anywhere. (I am also used to hunting, pecking, & doing keyword searches to find buried or hidden info.)

I also find that mileage requirement laughable. My center is about 60-65 miles or so away.  I don’t have medical clearance to drive myself that far anymore. So tell me why 40 miles or more makes that any different?

That radius does not make sense because on the East Coast with traffic flows, patterns, & roadways,  60-65 miles does at least equate to an hour & half timewise (sometimes more if you have to take side roads or detours). Most centers require you to be 2 hours or less from the center once listed.  So tell me how 100-150 miles lines up with meeting my listing requirements if 60-65 miles is pushing it?  (But that would require using common sense, oops!)

When I asked where in the policy this language was because I couldn’t find it in the transplant documentation, I was told it was in the Center of Excellence requirements, but I read through all of that when my policy was first issued & I couldn’t find it.

I looked in both my current & past plans again tonight even & found no verbiage.  I pressed for a page number or for more information while I was on the phone but instead of a response  I was asked some questions in regards to my listing they needed to clarify.

I let that go because I know case managers verify & check benefits once they were quoted but aren’t allowed to re-quote them or issue quotes (& technically I guess that information could be constituted as providing a quote).

She probably didn’t even have the policy to tell me where exactly it was.   But I can bet maybe that falls under the lovely “medically necessary” clause as well, too.

(It’s the most common loophole denial, especially if there isn’t a clear numbered exclusion. It’s the one “wild card” amongst all insurance carriers.  An exclusion that’s a vague exclusion  — all rights reserved if you will.  I get though that it does go the other way because with some treatments that medical necessity isn’t always readily apparent & with some supporting records or statement from a doctor, it can be proven as to why someone needs that care.)

I live in reality. I know benefits change & not everything is covered under my plan.  But with my background in insurance with taking calls exactly like these, I ask very specific questions to nail down a better response or get a clear clarification the first time to avoid being misquoted.

The fact that I was given bad information twice within 2 days on situations that were specific & important really does irk me.

Luckily, this is also why I started my transplant fund.

I knew there would be some expenses I couldn’t plan ahead of time for or predict until farther down the road.

Now at least I won’t have to wait 6 weeks to get a denial & then a bill & wonder what the hell happened.

I might even be able to negotiate a better deal or a lower charge going outside on some of this anyway.

But I’m just glad I have a case manager who was thorough & her covering case manager was also thorough to correct the mistake for me.

Because the time for me to find this information out would not be after I was told I had benefits, had made all the arrangements,  & then received the denial later.

I know this happens to people quite a bit, & what sometimes the insurance deems as medically necessary or not sometimes may not always align to what is actually in a person’s best interests or safety, either.

I don’t share these stories to make people cringe or fret about their policies.

I share them because even those of us who have been on the inside sometimes are subject to misinformation & rude awakenings from time-to-time, too.

Luckily, the place I have made such arrangements with as a back-up if needed CAN guarantee me a pick up at any hour.

When I informed them of this situation & the mix-up with the benefits, the service did provide me with an estimate, which I truly do appreciate.

The bonus is that it’s only about a mile or two from my house & they have everything arranged & pre-approved already so I can work it out with them directly without any paperwork or interference.  So I still have the option, in the end (should I need to use it).









7 thoughts on ““Medical Necessity”: 2 Cringe-Worthy Words

  1. Bravo for being so thorough!

    First, you will most likely have plenty of time to get to the hospital. The reality of “most” transplants is that there is a LOT of waiting time involved. Most initial calls contain the wording “we THINK we have an organ for you” including directions whether to head to the center or wait for another call. My center gives a 2 hour window for hearts but has also sent their own jet to pick up patients based on where they actually are when they get the call. Work with your center on the reality ….. not simply the window of time.

    Second, set up your own transport plan ….. friends, family or neighbors that are willing transport you. (Please note to them that it will be a time of high stress and the adrenaline will be pumping.) Have different routes in mind based on time of day …. can you take the interstate, or side streets/roads. And if that fails, call 9-1-1 …….. I’ve met a number of patients that used this method and it works. So what if you arrive in the back of a squad car …. all that matters is that you arrive.

    Best wishes!

    Liked by 1 person

  2. It’s also so none of my friends feel guilt for living life – if they’re in one location when the call comes I think it takes stress off if I just head down with transport and they meet me know what I’m saying? Rather than have to drive from there come home throw a few things together and race down . I know it will all work out but I like having backups for my backups and all my bases covered just in case 🙂


  3. Hi Nikki, this is a truly well documented and thorough description of the insurance benefit challenges facing those awaiting major organ transplant surgery. Kudos to you for preemptively addressing key aspects of your coverage with the case manager(s). Knockin’ Wood 4U!

    Liked by 1 person

  4. I go through the same issues, Very frustrating at times. I am on a waiver program and an HMO. I spend more time on the phone and do their legwork because I know the system well. I used to be an A/R supervisor in a home health/DME company. Small office, only five of us, so I was involved in visiting patients as well. I also have a rare disease, am paralyzed and confined to bed with the exception of doctor appointments. I am thankful that I stumbled upon your blog. Going to explore it further. This post was thorough and I hope eye-opening for some who read it that don’t understand the problems facing people with illnesses and disabilities with these programs and insurances. It is nice to meet you Nikki.

    Liked by 1 person

    • It’s great to meet you too! Thank you so much for sharing your experiences with me. I really appreciate that because for the longest I had wondered if these problems would ever make sense to others, but I guess it does certainly resonate with a few!


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s