February 10, 2025
by Gina G. La Prova, MD
The American Medical Association defines medical necessity as a concept that describes the need for health care services that are justified. These services must meet accepted standards of medicine and be supported by scientific evidence. Medical necessity is determined by:
- Patient’s medical condition: The severity and urgency of the patient’s condition is a primary factor.
- Clinical guidelines: The services must be in line with accepted standards of medical practice.
- Scientific evidence: The services must be supported by scientific evidence.
- Documentation: The patient’s medical history, symptoms, and relevant family history must be documented.
The most notable definition for medical necessity is “a health care concept that describes treatments and procedures that are justified by a patient’s medical condition. It is a legal doctrine in the US that is based on evidence-based clinical standards of care. Health insurance companies use the term to describe what is covered under a benefit plan. Generally, health plans only pay for services that are medically necessary.”
This definition, garnered from a number of legal and medical publications, is missing two key components: the human being (patient) and the physician, with numerous years of education and experience, who is seeing the patient first hand. It sounds manufactured to benefit only one party, the insurance company. The above definition is based on monetary gain not human life.
Catholic social teaching states that medical care is a basic human right and a fundamental need for human dignity. This teaching is based on the idea that health is a condition that affects a person’s ability to thrive.
As physicians with extensive training, should it not be our right to determine what is medically necessary for our patients to thrive based on evidence-based medicine? Should a health insurance company or what society states is relevant at the moment decide what is medically necessary without considering the evidence or long lasting effects and how it will impact the patient?
How is it beneficial to our patients for health insurances to make the following decisions even though most physicians would deem the treatment medically necessary:
- Changing a patient’s insulin formulation when the patient has been stable with a A1c of 6.2 (from 13) for 5 years?
- Denying coverage for chemotherapeutic drug to a 50-year-old woman with stage 4 breast cancer yet providing coverage for services such as gender affirming surgery that is not evidence based and has known long-term risks?
- Denying life-saving medication coverage to a patient in her 30s with Crohn’s disease, who eventually succumbs to her disease without access to proper care?
These are a few real-life examples of patients who were met with a medical system that failed them. These examples demonstrate a violation of the standard definition of medical necessity. Medically necessity has become what is medically relevant and financially beneficial. Lost in all this is the human person.
America has the best medical care in the world but is the sickest country and consumes the most pharmaceuticals in the world. We must, as Catholic physicians, stand by our patients and advocate for them and their dignity. We must be clear that medically necessary equates to what is best for our patients based on scientific evidence without looking at monetary gain or ideological pressure or fads. We must not conform. As Catholic physicians, it is our duty to stand together and persevere in doing what is right. I am hopeful that by doing this, sanity and common sense will return to health care in the coming years.
Dr. Gina La Prova serves on Catholic Medical Association’s (USA) Catholic Social Teaching and Justice in Medicine Committee and the Education Committee. She is an assistant clinical professor at the Alpert Medical School of Brown University.
