Deconstructing Medical Necessity from a Payer Perspective in 2025

Overview

The term medical necessity is frequently used throughout the healthcare system, yet its meaning can vary significantly depending on who you ask. While healthcare providers may view medical necessity through the lens of clinical judgment and patient care, payers—including Medicare—evaluate it through regulatory and reimbursement criteria.

Medicare’s stance is anchored in the Social Security Act, which states that no payment will be made for items or services under Parts A or B unless they are considered “reasonable and necessary” for diagnosis, treatment, or improving function. This excludes services not fitting these criteria, with certain exceptions like preventive and hospice care.

Because payer interpretations can differ substantially from those of providers, it’s essential to understand how medical necessity is defined and applied in coverage decisions. This webinar offers an in-depth analysis of payer medical necessity criteria, including medical policies, clinical guidelines, and the roles of National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). We’ll also explore how accepted clinical standards influence these decisions and share effective strategies for navigating and challenging medical necessity denials in today’s regulatory environment.

What You’ll Learn

Discrepancies between providers and payers in defining and applying medical necessity are a root cause of many coverage disputes. These misunderstandings can lead to denials, appeals, and potential revenue loss for healthcare organizations.

This session aims to dispel widespread myths and clarify the payer-provider divide by offering tactical approaches for addressing and appealing medical necessity decisions in 2025.

Learning Objectives

• Differentiate how payers and providers define medical necessity in the current landscape

• Locate and understand the use of LCDs, NCDs, and payer-specific medical coverage policies

• Identify key factors that influence medical necessity evaluations

• Recognize workflows and job functions impacted by medical necessity determinations

• Apply best practices to proactively manage and prevent medical necessity issues

Key Topics Covered

• Defining medical necessity from both payer and provider standpoints

• Pinpointing areas of disconnect and their operational consequences

• Overview of Local and National Coverage Determinations and their real-world impact

• Understanding insurance-specific medical policies that shape coverage decisions

• How to access and interpret NCDs, LCDs, and payer coverage guidelines

• The role of clinical best practices and standards in supporting medical necessity

• Strategies for challenging denials and building stronger appeals

• Proactive techniques to avoid common pitfalls tied to medical necessity requirements

Who Should Attend

This session is designed for healthcare professionals who deal with coding, billing, compliance, and medical decision-making, including:

• Certified Medical Coders

• Billing and Revenue Cycle Specialists

• Compliance Officers and Teams

• Private Practice Physicians

• Medical Auditors

• Managed Care Administrators

• Practice Managers and Office Leaders

• Chief Medical Officers and Operational Executives