Medical Necessity in California

October 25, 2013

UPDATED 10/21/2013 Unfortunately, the trial court did not rule on behalf of the plaintiffs. We filed with the appeals court to try and get that court to reverse the trial court in a special procedure that would expedite the case; the appeals court has not yet ruled on whether it will do so. Read our appeal.

ACS CAN believes that cancer patients should have the ability to work with their treating physician to determine appropriate care. Health insurance to cover these treatments should be adequate, available, affordable, and administratively simple. In many cases, a health insurance plan covers treatment that is "medically necessary," and there is a dispute about how medical necessity is defined and therefore what insurance must cover. In the fall of 2012, the Los Angeles County Medical Association, a cancer patient, and a woman suffering from debilitating pain sued insurer Health Net because the company had refused to pay for treatments it claimed were not medically necessary. The insurer's definition did not incorporate any deference to the treating physicians' opinion, arguably in violation of California law. The insurer claimed its review of treating physicians' recommendations ensures practice of evidence-based medicine. We filed as a friend of the court in order to explain that evidence-based medicine is not at odds with deference to the treating physician, and any definition of medical necessity should include such deference as long as the physician is acting reasonably.