Whose Medical Necessity Is it Anyway?

Medicare sets the tone for other insurance companies about which symptom justifies what test. Some of these coverage rules are hopelessly outdated and downright silly. Most patients have no idea how nitpicking this maze of rules really is. Most people probably believe that their doctor determines medical necessity.

I have such a hard time accepting that a healthy person with no symptoms is entitled to several free test panels per year as long as they are billed under the diagnosis Z00.00 – routine physical. (It’s almost ironic that the letter Z followed by four zeros spells out an exaggerated “zoo”.) At the same time I have to warn patients that tests to evaluate symptoms and diagnose disease have copays and may not be covered at all, because Medicare doesn’t know or acknowledge everything most doctors learned in medical school.

A classic example is BNP, brain natriuretic peptide. This is a screening test for heart failure, the symptoms of which are usually shortness of breath and leg edema. Only shortness of breath covers the test, not swollen legs. Go figure. These bureaucratic rules constitute what I call the parallel universe of Metamedicine.

I question the cost savings of these restrictions for essentially routine testing. Doctors waste time wading through the Byzantine rules, laboratories waste time chasing silly numeric codes, and sometimes middlemen eek out profit from overseeing our work. I can understand that we need stringency about big ticket genetics panels (like in the fraudulent faxes I get for Medicare patients whose data must have been stolen), but an iron level? In a system that spends twice as much on healthcare as any other country on earth? Look at this:

Restless Leg Syndrome is sometimes caused by iron deficiency, even if there is not yet significant anemia. This was shown by Professor Ekbom at Uppsala, my alma mater. But G25.81 (RLS, Ekbom’s Syndrome) won’t buy you an iron level. I have a fax on my desk right now from the lab, asking me to find another diagnosis? Do I just pretend my patient has anemia?

Imaging is even trickier than blood tests when it comes to “medical necessity”. My 2019 post The Cruelty of Managed Medicare illustrates the frustrating, torturous, heartbreaking challenge of getting patients with nearly obvious cancer the proper imaging to make their diagnosis. There should be an ICD-10 code for “looks like cancer, need to figure out where”!

The Cruelty of Managed Medicare

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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