Medical necessity isn't the chief issue behind most consumer appeals of HMO coverage decisions, according to a report in today's Journal of the American Medical Association. Nearly 60% of consumer appeals to two California HMOs from Jan. 1, 1998, through the first half of 2000 contested the contractual scope of coverage or access to out-of-network care instead of medical necessity, researchers said. In appeals involving medical necessity, enrollees won approximately half of the cases. The three most common procedures involved in appeals -- accounting for 57% of cases -- were gastric bypass, breast alteration and varicose vein removal. The study included nearly 4,000 appeals. Read the study abstract. -- by Patrick Reilly
Most HMO appeals don't involve medical need: study
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