The Tennessee legislature passed a law concerning TennCare, the state's
Medicaid program, including a definition of medical necessity that has aroused
considerable concern among health care professionals and advocates for the
Former APA president Paul Appelbaum, M.D., made the following comments
about the definition:
Traditional definitions of medical necessity have turned on whether or not
the treatment in question meets professional standards of care. The proposed
TennCare definition rejects professional judgment in favor of arbitrary
standards that may be particularly problematic for psychiatry.
In requiring "scientifically supported evidence" and"
empirically based objective clinical scientific evidence" for
treatments to be considered safe, effective, and nonexperimental, the new
definition could exclude from coverage many widely accepted treatment
approaches that are difficult to test empirically (for example, psychodynamic
and other forms of psychotherapy).
Moreover, since the patients enrolled in clinical trials often differ from
those seen in everyday practice (for example, patients with comorbid substance
abuse disorders are typically excluded from clinical trials), TennCare
reviewers will frequently have at hand a ready excuse to deny any care for
which they would rather not pay.
The requirement that any treatment must be the "least costly
alternative course of diagnosis or treatment that is adequate for the medical
condition of the enrollee" threatens endless disputes over what
constitutes adequacy—a term without referent in clinical practice. If a
treatment controls symptoms well enough that a person can return to work but
doesn't lead to complete symptom resolution or reduce the risk of recurrence,
is that adequate? This component of the definition would mean open season on
clinical judgment and truly effective care in situations where less-expensive
Finally, psychiatrists often use medications approved for a specified
condition to treat a different condition, frequently because pharmaceutical
companies have elected not to obtain FDA approval for additional indications
after a drug is on the market. The new criteria create at least five standards
that must be met before the medication will be covered by TennCare, each one
conferring enormous discretion on reviewers, essentially allowing them to
disapprove "off-label" indications at will.
The traditional medical necessity standard was implemented in an effort to
restrain insurers from pursuing their own financial interests in making
coverage determinations. TennCare's proposed redefinition, if approved by the
federal government, would remove much of the incentive for any Medicaid
program to provide generally accepted levels of care.