Medical Necessity
   HOME

TheInfoList



OR:

Medical necessity is a
legal doctrine A legal doctrine is a framework, set of rules, Procedural law, procedural steps, or Test (law), test, often established through precedent in the common law, through which judgments can be determined in a given legal case. For example, a doctrine ...
in the
United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...
related to activities that may be justified as reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. In contrast, unnecessary health care lacks such justification. Other countries may have medical doctrines or legal rules covering broadly similar grounds. The term clinical medical necessity is also used.


Implementations of doctrine


Medicare

Medicare pays for medical items and services that are "reasonable and necessary" or "appropriate" for a variety of purposes. By statute, Medicare may pay only for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member" unless there is another statutory authorization for payment. Medicare has a number of policies that describe coverage criteria, including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), formerly known as Local Medical Review Policies (LMRP).For more information, see th
Centers for Medicare & Medicaid Services
website.
In a small number of cases, Medicare may determine if a method of treating a patient should be covered on a case-by-case basis. Even if a service is medically determined to be "reasonable and necessary," coverage may be limited if the service is provided more frequently than allowed under Medicare coverage policies.For more information, see
Certificate of medical necessity In the US a certificate of medical necessity is a document required by Centers for Medicare and Medicaid Services to substantiate in detail the medical necessity of an item of durable medical equipment or a service to a Medicare beneficiary. The ...

MedicareLaw's "Reasonable and Necessary"
o
GoTelecare: Medical Billing


Specific instances


Medical use of marijuana

The use of
cannabis ''Cannabis'' () is a genus of flowering plants in the family Cannabaceae that is widely accepted as being indigenous to and originating from the continent of Asia. However, the number of species is disputed, with as many as three species be ...
(also known as marijuana) for medical purposes is a notable medical necessity case. Cannabis is a plant whose active ingredients are widely reported by patients to be effective in pain control for various conditions, usually neuropathic in nature, in which common painkillers have not had great benefit. However, as a Schedule I drug under the
Controlled Substances Act The Controlled Substances Act (CSA) is the statute establishing federal government of the United States, federal drug policy of the United States, U.S. drug policy under which the manufacture, importation, possession, use, and distribution of ...
, it is illegal and is targeted by government, police, and anti-drug campaigners. In some states, possession is decriminalized even for non-medical purposes, but in other states possession, is a felony offense. In this case, the doctrine of medical necessity would be used by patients who believed marijuana to be beneficial to them if they were charged with the use, growing, or production of an illegal controlled substance relating to marijuana. Robert Randall successfully used a medical necessity defense when he was charged with illegal possession of cannabis to treat his
glaucoma Glaucoma is a group of eye diseases that can lead to damage of the optic nerve. The optic nerve transmits visual information from the eye to the brain. Glaucoma may cause vision loss if left untreated. It has been called the "silent thief of ...
. The case, ''United States v. Randall'' (1976), is "The first successful articulation of the medical necessity defense in the history of the common law, and indeed, the first case to extend the necessity defense to the crimes of possession or cultivation of marijuana". In several medical marijuana cases, the patients' physician has been willing to state to the court that the patient's condition requires this medicine and so the court should not interfere. However, the
US Supreme Court The Supreme Court of the United States (SCOTUS) is the highest court in the federal judiciary of the United States. It has ultimate appellate jurisdiction over all Federal tribunals in the United States, U.S. federal court cases, and over Stat ...
outrightly rejected that defense in the landmark case '' United States v. Oakland Cannabis Buyers' Cooperative'' (2001) which ruled that there is no medical necessity exception to drug laws and that the federal government is free to
raid RAID (; redundant array of inexpensive disks or redundant array of independent disks) is a data storage virtualization technology that combines multiple physical Computer data storage, data storage components into one or more logical units for th ...
,
arrest An arrest is the act of apprehending and taking a person into custody (legal protection or control), usually because the person has been suspected of or observed committing a crime. After being taken into custody, the person can be question ...
,
prosecute A prosecutor is a legal representative of the prosecution in states with either the adversarial system, which is adopted in common law, or inquisitorial system, which is adopted in Civil law (legal system), civil law. The prosecution is the ...
, and imprison patients who are using medical marijuana no matter if the medicine is crucially necessary to them. On the other hand, in '' Gonzales v. Raich'' (2005), the Ninth Circuit Court of Appeals told a patient in extreme pain that state law allowing medical use could not be relied on, but if arrested, the user could seek to use medical necessity as a defence. In
Maryland Maryland ( ) is a U.S. state, state in the Mid-Atlantic (United States), Mid-Atlantic region of the United States. It borders the states of Virginia to its south, West Virginia to its west, Pennsylvania to its north, and Delaware to its east ...
, a bill signed by Governor Robert Ehrlich became law in 2003 to permit patients to use medical necessity defense to marijuana possession in the state. The maximum penalty for such users cannot exceed $100. However, the law does not prevent federal prosecution of patients since the federal law does not recognize medical necessity.


See also

*
Certificate of medical necessity In the US a certificate of medical necessity is a document required by Centers for Medicare and Medicaid Services to substantiate in detail the medical necessity of an item of durable medical equipment or a service to a Medicare beneficiary. The ...
(CMN)


Notes


References

{{reflist


External links


Your Medicare Coverage
from medicare.gov
Medicare Coverage Database
which includes NCDs, LMRP/LCDs, as well as NCAs & CALs, from cms.hhs.gov
Physician Fee Schedule lookup
at cms.hhs.gov
''Defining Medical Necessity Under the Patient Protection and Affordable Care Act''
at academia.edu, by Daniel R. Skinner, published in the journal
Public Administration Review ''Public Administration Review'' is a bimonthly peer-reviewed academic journal the field of public administration. It was established in 1940 and has been one of the top-rated journals in the field. It is the official journal of the American Societ ...
(2013).
''Medical Necessity: Health Care Access and the Politics of Decision Making''
by Daniel Skinner, a book published by the University of Minnesota Press (2019). * Charles Martin, "Medical Use of Cannabis in Australia: 'Medical necessity' defences under current Australian law and avenues for reform" (2014) 21(4) ''Journal of Law and Medicine'' 875.
''Florida's Medical Necessity Defense, Reconsidered''
by Miami attorney Jared H. Beck Medicare and Medicaid (United States) Legal doctrines and principles