"Medically unnecessary" letters create frustrating puzzles

Medicare's "medically unnecessary" letters are frustrating puzzles to the many Texas physicians who receive them. While the letters question the medical necessity of care, they provide physicians with no basis for understanding and responding to that allegation. Medicare uses computerized screens to review claims, and it is those screens that are primarily responsible for the generation of "medically unnecessary" letters. The accompanying list of Medicare review screens provides a general clarification of what Medicare is looking for in the review process. The word "general" is an important qualification: there is no guarantee that a physician will be able to identify from the list the particular screen that has caused Medicare to request more information about a particular claim. But the list will help the practitioner in understanding what Medicare sees as the boundaries of customary medical practice and, in some instances, will help the physician respond to Medicare's request for additional information. With that broad introduction Texas Medicine presents the following guide to Medicare's claims screening criteria. It was prepared by the Texas Medical Association's Division of Medical Economics based on materials published by Medicare.