Understanding Medical Necessity

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PDF - Understanding "Medical Necessity" In Kansas

PDF - Everything You Wanted to Know about Medical Necessity in Medicaid in Kansas (full 5-page guide)

Understanding "Medical Necessity" In Medicaid
For Adults and Children in Kansas

People often report issues with the Managed Care Organization (MCO) doctor denying a needed service and saying it is not "medically necessary." This resource has information about the "medically necessary" standard and how to work with your own doctor to get the services you need approved!

What Does "Medically Necessary" Mean?

“Medically Necessary” is the standard a service or device must meet to be covered by
Medicaid. A service or device must meet five criteria in Kansas law:

  1. Recommended by your doctor - your doctor says you need it. 
  2. Has a medical purpose - it treats a health or disability condition. 
  3. Right amount/type - it's the most appropriate level of care. 
  4. Proven to work - it's effective, based on medical evidence. 
  5. Cost-effective - it's a good use of resources for your condition. 

It's a good idea to submit your doctor's letter as a supporting document when making a request for services or devices to Medicaid. A doctor's letter that clearly touches all 5 rules above gives you the best chance of approval. 

Tips to Get Services, Supports, Devices, or Assistive Technology (AT) Approved as Medically Necessary

  • - Gather evidence early. Have your doctor provide supporting notes or records. 
  • - Submit all your supporting documents at the start. Don't wait for a denial to provide your supporting documents. 
  • - Ask your doctor to write a strong "medical necessity" letter that covers the five points above. 
  • - Keep copies of all forms, emails, and letters you send. 

If Your Request Is Denied

  • - Ask your doctor to update their letter or provide more documentation
  • - File an internal appeal with your MCO
  • - If that doesn't work, you can appeal to the Office of Administrative Hearings (OAH)

A clear, detailed doctor's letter is your best evidence in an appeal. 

Special Info for Kids Under 21 (EPSDT)

EPSDT stands for Early and Periodic Screening, Diagnostic, and Treatment. Under EPSDT, Medicaid must cover any service that helps correct or “ameliorate” (which means to make better, more tolerable, or maintain functionality) a condition for youth under 21.

Sometimes people get stuck in “limbo” between exhausting EPSDT services (including
waiver-like services, like personal care attendants) and applying for a Home and Community Based Services (HCBS) Waiver Crisis Exception.

If your child is under 21 and waiting for a waiver: 

  • - You must first apply for needed services under EPSDT. 
  • - The state won't review a crisis exception for a waiver slot until the MCO says "yes" or "no" to providing the service. 

MCOs make it very difficult to understand how to navigate EPSDT. Keep written records of every request and response. 

To move forward: 

  1. Use DRC's EPSDT Fact Sheet and physician screening form. These tools may help you get an answer from EPSDT faster. Your doctor can use the physician screening form to describe the medical necessity. 
  2. Have your doctor explain how the service or device will correct or address your child's condition. 
  3. Email the completed form and documentation to your care coordinator if possible, and ask them to review it under the EPSDT criteria. 
  4. If your MCO refuses to review it or keeps delaying, file an internal grievance. Use DRC's KanCare Grievance/Appeals fact sheet for information about your rights.

Want to learn more? View DRC's full 5-page guide about medical necessity in Kansas.

Understanding Medical Necessity