Who Should Determine “Medical Necessity”?

The following is a guest post.

These days, there is a lot of talk about expanding scopes of practice for the group of folks who used to be called “physician extenders” and then “midlevel providers” and more recently “non-physician providers,” many of whom are now getting degrees with the title “doctor” incorporated.  While it seems to vary, these folks may include nurses, physician assistants (one day to be called “physician associates” perhaps), pharmacists, and more.  Lots of forums are discussing whether folks who are not doctors should be calling themselves “doctor” or whether they should be expanding their scope of practice via legislative rather than educational means. But a recent personal anecdote has made me wonder about a slightly different question: should non-physicians be able to certify “medical necessity”?

Two family members are covered under the same insurance policy.

He has had a history of knee injury, related surgery, and subsequent successful rehabilitation. He recently ran a marathon, and now has new knee pain that has persisted after 8 weeks of conservative therapy at home. After a long wait for an appointment slot, he finally sees an orthopedic surgeon with knee expertise. The doctor recommends an MRI to evaluate the nature of his ongoing pain. 

She has chronic back pain that seems to be acting up, and sees a chiropractor mostly out of convenience, since the office is in the strip-mall near her home and he can see her anytime as a walk-in. After just two sessions with the chiropractor, he suggests an MRI, since she isn’t responding as well as he had expected to the adjustments.

The insurance company immediately approves the chiropractor’s MRI, but denies the orthopedic surgeon’s.  The request was appealed, and again denied, on the grounds that it was not medically necessary. The insurance company issued a requirement that the physician first document the patient’s participation in a physical therapist’s prescribed self-care routine for at least 6 more weeks (recall that the patient has essentially already done this for 8 weeks, having had formal PT for the knee in the past, and familiar with the appropriate self-care, but this did not satisfy the payer). Only after jumping through this hoop may the doctor meet the standard of “medical necessity” to obtain the MRI.

Lest I be misunderstood, I do not object to the idea that the chiropractor can order imaging tests. A chiropractor is an autonomous professional after all, and is a doctor of chiropractic, just as a dentist is a doctor of dental surgery, and an optometrist is a doctor of optometry (but that doesn’t qualify him to do eye surgery– a debate for another time.).

In the modern landscape of myriad healthcare providers and payers, if a non-physician can certify “medical necessity,” surely a specialist physician should be able to as well.

Marjorie Stiegler is an anesthesiologist. She blogs about patient safety and decision-making errors at www.marjoriestieglermd.com.