Medical Necessity in Private Health Plans: Implications for Behavioral Health Care

Substance Abuse and Mental Health Services Administration Medical Necessity in Private Health Plans: Implications for Behavioral Health Care This report addresses how the term medical necessity is defined in private health insurance coverage decisions. It summarizes a review of the literature, an extensive review of legal cases that challenge insurer decisions, materials prepared by the insurance industry, consultation with experts in the field, a review of investigations conducted by State departments of insurance and attorneys general, and interviews with health care executives regarding the decision making process itself. The report does not explore factors that can affect access to care . . .