Question:
How do I find out what 'medical necessity' means to my particular insurance..

I have tried to call on numerous occations to my particular Insurance Company, ( CMS AHC). I have asked them what is their definition of a 'medical necessity'. I know that each insurance company is different, and their requirements are different. Do I have to be on my death bed?? Are a few co-morbidities enough? Which ones do they accept?? These are all questions that I know you all can't answer. But how can I get my insurance company to answer them? Does anyone know of a website I could probably go to? This is all very frustrating, as I am sure you all can understand, (personally). Each time I speak with them, all they say is that it has to be medically necessary. That's it.. no other information. They also made me cancel my appointment with my regular doctor, (for a referral), and told me to just go straight to the surgeon. Does that sound right to you? Two different people from the insurance company told me that. Ahh Insurance companies, don't you love 'em?? :)    — Annie R. (posted on April 5, 2001)

April 5, 2001
Anne, My insurance also says "medically necessary". What they described to me was any co-morbidity. ie: sleep apnea, diabetes, hypertension (high blood pressure), joint disease or pain, heart problems, osteoarthritis or any thing in family history that put me at a higher risk for heart disease, diabetes and/or cancer. Also, I had to be 100 lbs. or more overweight, with a BMI of 40 or more. OR 200% of ideal body weight with no co-morbidities. Hope this helps. If you are not sure, call your insurance back and ask to speak with a supervisor and get the answers you need. Talk to your doctor, a lot of times they know what your insurance might consider "medically necessary".
   — Tere F.

April 5, 2001
Anne, You might also want to contact whoever the ins. is thru. Your empoloyer,spouses. I contacted my husbands Health Benefits Coordinator and she mailed me a copy of what is covered and the criteria. Maybe then that will give you some guidlines. My guidelines for "medically necessary" are just meeting their criteria since it's all based on "medical" facts. Supervised weight loss(physician),and medically documented co-morbidities. Including meeting their BMI requirements. Best of luck
   — Linda M.