Insurance – Medical Necessity – Part 1

Center for Environmental Medicine is a medical practice providing health care to families and individuals from a holistic approach; applying therapies studied from allopathic (conventional or contemporary medicine whose practitioners prefer to claim “The Standard of Care”), alternative, integrative, complementary and functional medicine or CAM.  These services in the health insurance industry may sometimes fall under the category of “not medically necessary” and is further addressed below.  This is true for all practices.  Additionally, with strictly conventionally practices you will see tests and services that do not meet medical necessity.

The ultimate purpose of our work is to serve and help people regain health and sustain wellness.  Our vision is to create a center that seeks to reach out to the public, to assist in the healing process through detoxification and restoration of the inherent balance in the body with the safest therapies available. Ultimately the goal is to treat the whole body which includes emotional and spiritual health. Our methods may include nutritional biochemistry, lifestyle modification, bodywork, chelation therapy, and bioenergetics.  We address target amino acid which ultimately accesses the balance of neurotransmitter and adrenal support. We provide diagnostic laboratory tests including esoteric tests not generally accepted by mainstream medicine.  We seek to exchange ideas, educate and assess all with a holistic, open-minded and functional medicine approach.  Every member of the health care team, which includes the patient, must understand when we give our best, then we ask for a patient who comes with integrity and interest in resolving their health issues. 

Many people look to their insurance in helping to meet their health care needs.  While we cannot guarantee coverage, we have a good understanding of what information insurance is seeking in order to process a claim efficiently, accurately, and to the benefit of the insured.  We will ask for assistance from the patient in providing supportive assessments related to history which is how we accomplish meeting strict requirements by the insurance company to meet medical necessity.  To be clear, it isn’t always possible.  When insurance is not available, we provide the patient with viable options which may help to accomplish their goals.

The term “medical necessity” is often misunderstood by the patient.  Understanding the definition of this term prior to medical treatment often relieves a patient of frustration as they plan their strategy of an affordable health goal. 

From Wikipedia, a free web encyclopedia related to medical information, medical necessity is a legal doctrine related to activities which may be justified as reasonable, necessary, and/or appropriate, base on evidence-based clinical standards of care.  Definitions to each plan are outlined within the insurance contract to the individual consumer. 

The insurance company may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury…”  Your doctor may have a different opinion outside of this definition based on his clinical experience and scope of practice.  While the insurance company’s goal is to cover specific benefits only, the doctor’s goal is to achieve your healthcare goals. Your insurance company allows for your right to choose the type of care you select, but they reserve the right to make the final determination if they will pay for a service or not.  Ultimately, it is your responsibility to understand what your insurance benefits are. 

Benefits are based on the patient’s specific contract.  Co-pays by law are due before insurance can be billed.  In some cases, a laboratory test may be only partially covered.  In all cases we tell a patient in advance that we do not guarantee coverage, inform them what is usually not covered and allow them to make the choice of how they approach their health.

Center for Environmental Medicine


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