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Health Insurance Medical Policy Explained

Health Insurance Medical Policy Explained

By: Eric Bricker, MD

Medical Policy are plan documents that support health insurance coverage decisions based on medical necessity.

Medical Policy is all the ‘Buts’ in your health insurance… “You have coverage, BUT not for this.”

As an example, one major insurance carrier has a list of 259 areas of Medical Policy filled with what it will not cover.

Medical Policy is different across health insurance companies.  For example, Maternal Ultrasound coverage at United, Aetna, Blue Cross Plans and Cigna is different.

Medical Policy is often different than the clinical judgement of a patient’s doctor.

In that case, a person’s health insurance will not pay for what the doctor has ordered and will deny payment.

These denials can and should be appealed by patients and their doctors.

However, this process of appealing Medical Policy denials is time-consuming and complicated.

An alternative way of minimizing and proactively addressing denials due to Medical Policy is to have a high-quality doctor that already practices evidence-based medicine. 

That doctor’s judgement will not be an outlier regarding Medical Policy in many circumstances.  Alternatively, when that doctor wants to order a test, perform a procedure or prescribe a medication that is outside of Medical Policy, they are likely to have very firm clinical grounds for their decision and are better prepared to overturn the insurance carrier denial.