Medical Necessity Webinar Series

In the spring of 2022, The Catalyst Center and the National Coordinating Center for the Regional Genetics Networks (NCC), the organization that develops the Genetics Policy Hub, are holding a three-part webinar series to help healthcare providers navigate the medical necessity.

    • Part 1- Define and discuss the use of evidence to form medical necessity criteria and policy (recording below);
    • Part 2- Medicaid and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)- The Title V and Medicaid Relationship
    • Part 3- Practical Application of Medical Necessity: Understanding Prior Authorization Process, Requesting Authorizations, and Denials and Appeals.

    Speakers in this series include:

    • Erin Beaver, MS, CGC Licensed Certified Genetic Counselor, Missouri Baptist Medical Center
    • Julie Kaylor, MS, CGCDirector, Medical Affairs, Managed Care Guardant Health
    • Nicole Guysi, Family Leader
    • Demeatrice Nance, CCHW Research Coordinator, Pediatric Institute, Cleveland Clinic Children’s
    • Tammy Jones Program Coordinator, Genetic Metabolic Nutrition Research & MNT4P Program, Emory University
    • Jeff Schiff, MD, MBA Senior Scholar, AcademyHealth
    Upcoming Webinars Registration

    Part 2- May 20th at 1 PM ET

    Part 3- June 2022
    Registration Coming at the end of May

    Define and Discuss the Use of Evidence to Form Medical Necessity Criteria and Policy

    In Part 1 of the Medical Necessity Webinar Series, medical necessity is defined, how evidence is used by insurance companies is discussed, and the role of medical necessity was presented through two genetic cases. Learning objectives for this session include:

    • Define what is medical necessity.
    • Describe how evidence is evaluated to determine whether a test or service is deemed medically necessary.
    • Explain how the evaluation of benefits and costs to families and to payers are considered when determining medical necessity policy.

    Additional Resources

      Looking for additional resources to help you navigate medical necessity? Explore some select resources from partner organizations.

      The Catalyst Center Resources

      State Medicaid programs are required to provide Medicaid enrollees under age 21 with comprehensive and preventive health care services through the Early Screening and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Federal law requires states to cover “medically necessary services” under the EPSDT benefit “whether or not such services are covered under the State plan.”  The federal statute does not define “medical necessity” but instead describes a broad standard for coverage. States can, therefore, establish their own parameters for medical necessity decisions so long as those parameters are not more restrictive than the federal statute. In March 2021, with support from the Catalyst Center, The National Academy for State Health Policy (NASHP) conducted a 50-state scan of medical necessity definitions used by state Medicaid programs for their EPSDT benefit, updating a previous scan conducted in 2013. This resource presents definitions of medical necessity from all 50 states and the District of Columbia.

      Heartland Regional Genetics Network (HRGN) Resources

      Julie Taylor and Erin Beaver partnered with HRGN to develop a genetic testing toolkit. The toolkit includes:

      • Patient glossary for terms related to insurance coverage
      • Sponsored Testing List
      • Prior Authorization Information
      • How to do a Prior Authorization
      • What needs to be in a Letter of Medical Necessity
      • Letter of Medical Necessity Templates (General, Whole Exome Sequence, Whole Genome Sequence + Whole Exome Sequence, Chromosomal Microarray)