By Stephen Schultz (Editor’s Note: This article was inspired by a conversation I had with a mother whose son was in crisis.) The concept of Medical Necessity sits at the center of modern behavioral health insurance coverage. At its core, it is a reasonable and well-intended standard: to ensure that individuals receive the right level of care at the right time, while avoiding unnecessary or overly intensive services. When applied thoughtfully, Medical Necessity protects both patients and systems. In practice, however—particularly when authorizing residential or inpatient care for adolescents—the application of Medical Necessity can produce outcomes that run counter to its original purpose. When Cost Containment Becomes Care Shaping Medical Necessity standards were developed, in part, to reduce excessive utilization and control escalating costs. The underlying assumption is that less restrictive, lower-cost services should be attempted first, with higher levels of care approved only whe...
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