Medical necessity guide

Our employer-sponsored health insurance plans provide major medical coverage for healthcare services and prescription drugs. Sidecar Health will cover services prescribed by a doctor for health reasons (deemed medically necessary), but things like cosmetic and elective procedures may not be covered. If you break your nose, you will be covered. But if you think you’d look better with a different nose, you’re on your own. In this resource, we aim to simplify the concept of medical necessity and address common questions you may have about its application within your health plan.

With more questions, contact our Member Care team at 855-282-0822.

What is medical necessity?

Medical necessity refers to the determination that a particular healthcare service, or prescription drug is essential for the diagnosis, treatment or prevention of a medical condition. This determination considers the patient's unique health needs and current medical standards. Whether something is medically necessary is determined by Sidecar Health.

What requires medical necessity?

For any healthcare service or prescription drug to be eligible for benefits, it must be medically necessary. When atypical utilization appears in a claim (i.e. having three hours of physical therapy daily during rehabilitation or having weekly lab tests) Sidecar Health requests more details to understand your care plan and ensure your benefits are applied correctly. This process is called a medical necessity review.

What are medical necessity reviews and how do they work?

Medical necessity reviews assess whether the type and amount of healthcare services or prescription drugs are genuinely required for the diagnosed medical condition(s). Additional information may be needed to evaluate the treatment plan and underlying conditions during this review. It's all about ensuring your healthcare is necessary and beneficial. If our clinical team needs to review the medical necessity of a healthcare service or prescription drug, here’s (generally) what you can expect:

1. Sidecar Health may ask you for more information about your submitted claim. Look out for an email or a phone call from us.
2. Member gathers more information to submit to Sidecar Health: This could include 'MyChart' notes, records from a specific provider or a note from your doctor. We use this information to determine if the healthcare services or prescription drugs are necessary and appropriate for treating a medical condition or if they're optional. Below is a list of common supporting information, by care type.

Note: The medical necessity of a claim is assessed according to the regulatory requirements specific to each state for major medical plans. The review team includes RNs, a Medical Director, and a licensed review agent, ensuring compliance with state regulations.

What can you upload to support medical necessity?

If your care is under review, you can use the list below to help you identify the most valuable supporting information to upload for a successful review.

Note: Depending on the treatment being assessed, documentation from other aspects of your care, such as visit details or test results, aids us in gaining a comprehensive understanding of your overall healthcare. This not only facilitates our review process but also ensures we consider the broader context of your well-being.

• Diagnostic tests to identify medical conditions
  • Upload the prescription with symptoms or diagnosis
  • Upload the consult notes and discharge summary from the provider who ordered the tests
• Medically necessary treatments and surgeries
  • Upload the consult notes and discharge summary from the provider who ordered the treatments and surgeries
• Prescription medications
  • Upload the prescription with diagnosis and days of supply included
  • Upload the consult notes and discharge summary from the provider who prescribed the medications
  • Note: Your policy has prescription coverage limitations. It does not pay a Benefit Amount for medications that are primarily for weight loss, fertility-related related treatment, sexual dysfunctions/inadequacies, vitamins, supplements, OTC non-preventive drugs etc.; these non-covered drugs are not reviewed for medical necessity, these are excluded from your coverage
• Rehabilitation and therapy services
  • Upload the consult notes and discharge summary from the provider who is administering the rehabilitation and therapy services
  • Note: Your policy has frequency limitations for these services, and this can be found under your Schedule of Benefits. Frequency limitations are not reviewed for medical necessity and will be denied based on policy limits.
• Medical equipment and supplies required for treatment
  • Upload the prescription with diagnosis rule out
  • Upload the consult notes and discharge summary from the provider who ordered the DME’s/supplies
  • Note: Your policy has frequency limitations for these services, and this can be found under your Schedule of Benefits. Frequency limitations are not reviewed for medical necessity and will be denied based on policy limits.