Insurance carriers routinely cite evidence-based clinical guidelines when denying treatment authorization. However, a number of insurance industry resources confirm that insurance medical decision makers must consider the patient’s unique medical condition and should deviate from the clinical guidelines when appropriate.
Requesting deviation from the guidelines will typically require an appeal focusing on the patient’s unique medical needs and why application of the guideline is not appropriate. Some of the specific factors to address in such an appeal include the following:
- Patient’s previous treatments and discussion of failed treatment attempts and unwanted side effects
- Patient’s secondary diagnoses which potentially complicate treatment
- Any anatomical anomalies or age-related factors (pre-natal or geriatric challenges)
- Ongoing diagnostic assessment for unexplained symptoms/atypical disease/disorder presentation
Further, the guideline itself can be called into question if it does not appear to adhere to current industry quality care standards and incorporate the latest treatment options. Some of the specific questions useful for assessing the quality of the guideline include the following:
- How frequently the guideline is updated to incorporate recent medical developments
- Patient demographic used to develop standards, ie, did the guideline development include studies involving a diverse patient population inclusive of prenatal patients, geriatrics and minorities to ensure appropriate application across a diverse population.
A study of medical necessity decisions made by private health plans discusses the widespread adoption of clinical guidelines for use in medical necessity decision making. According to this study entitled “Medical Necessity in Private Health Plans: Implications for Behavioral Health Care“, several insurer medical directors acknowledged that clinical guidelines are simply a decision making tool and should allow for flexible implementation.
“Interviewees stated that guidelines are not mandates or absolute protocols; rather, they are considered ‘guideposts’ to be informed by, and adapted to, individual circumstances and psychosocial needs of patients. Ongoing audits, performance measurement of in-house care managers and contracted providers, and member and provider satisfaction surveys are used to monitor the appropriate use of treatment guidelines in medical necessity decisions and to build in quality improvements at all levels of decision making,” states the study, available online at http://download.ncadi.samhsa.gov/ken/pdf/SMA03-3790/SMA03-3790.PDF.