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Original Question

Read the vignette details and answer the Constructed Response Questions Vignette: Who Determines Medical Necessity? Ann Baker, a 45-year-old accountant, was a member of a national HMO for 20 years. She obtained care from HMO primary care providers on a regular basis. Ann never failed to pay monthly premiums over a 20-year period. Her persistent headaches could not be managed with over-the-counter medications. Following through on her HMO physical exam, she had blood tests, but nothing significant surfaced. The physician prescribed medication for her headache; she returned a week later with no improvement. Because there was no neurologist on the HMO physician panel, Ms. Baker was referred to a well-known neurologist in the area. After reading Ann’s chart results, the neurologist recommended a CAT scan, which revealed an abnormality in the brain. The neurologist recommended a magnetic resonance arteriogram (MRA); this necessitated a one-night stay in the hospital. Ann underwent surgery, which relieved arterial pressure, and her headaches abated. While recuperating, she received a bill from her HMO for neurologist treatment. The HMO reimbursed the neurologist surgery but denied MRA on the grounds that it was investigative. The neurologist wrote to both Ann, the member, and the HMO that despite HMO denial, the MRA had been medically necessary. Not only did the HMO medical director not reconsider reimbursement, he wrote the neurologist directly, stating that the letter to the member was significantly inflammatory and that the neurologist’s persistent pattern of pitting the HMO against its members might place his relationship with the HMO in jeopardy. Ann Baker repeatedly used the HMO grievance procedure; after two years of denials, the HMO finally reconsidered and reimbursed. Constructed Response Questions: Who determines medical necessity? Ms. Baker’s HMO contract states clearly that ultimately it is the HMO that decides. Should HMO members get pre-approval for specialist tests from the HMO? Are HMO grievance procedures effective and worth the time and effort? Isn’t it clearer to assess medical necessity after the fact?

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