Determination of Medical Necessity

[checkyourmirror]

I am in WA state and my Ex-wife has custody of my two children. In the decree/child support I am required to split paying for any non-insurance covered medically necessary work. My question is what determines medical necessity? If the Insurance company denies the claim or medical necessity submit by the doctor, does that make it medical necessary if the doctor say it is but the insurance says it isn't?

 

[stealth2]

If the Insurance company denies the claim or medical necessity submit by the doctor, does that make it medical necessary if the doctor say it is but the insurance says it isn't?

Insurance companies frequently deny necessary treatments/procedures. If it were MY child, I would take the word of an actual doctor over that of a pencil pusher trying to save his/her company money (no offense intended to anyone working in this position!).

 

[ecmst12]

Services may not be covered even if they are necessary, many exclusions have nothing to do with medical need. What is the specific circumstance that you are asking about?

 

[checkyourmirror]

Services may not be covered even if they are necessary, many exclusions have nothing to do with medical need. What is the specific circumstance that you are asking about?

The issue is with a LapBand for my daughter and she is eighteen and not currently enrolled in school so I am not compelled for child support. She lives with her mother full time and I feel other paths have not be used nor could be proved. I don't want to get into the debate of LapBands.

There are really two issues as I see it:

1) The medical necessity versus elective and my feeling is the Insurance company being the "rule" of what is a necessity. Also nothing else has been done, no weight watchers, no exercise, etc
2) Since she is not enrolled in school and eighteen, I have no support obligation and hence don't have to pay anything if I do not want to however I do have her on my medical insurance policy. If she does enroll in school I guess this might change.

PS: I am supportive of working on this but I don't want to jump to surgery also her mother is making the decision not me and she has enough money to do this since it is her sole decision and want take my opinion into consideration.

 

[stealth2]

The issue is with a LapBand for my daughter and she is eighteen and not currently enrolled in school so I am not compelled for child support. She lives with her mother full time and I feel other paths have not be used nor could be proved. I don't want to get into the debate of LapBands.

There are really two issues as I see it:

1) The medical necessity versus elective and my feeling is the Insurance company being the "rule" of what is a necessity. Also nothing else has been done, no weight watchers, no exercise, etc
2) Since she is not enrolled in school and eighteen, I have no support obligation and hence don't have to pay anything if I do not want to however I do have her on my medical insurance policy. If she does enroll in school I guess this might change.

PS: I am supportive of working on this but I don't want to jump to surgery also her mother is making the decision not me and she has enough money to do this since it is her sole decision and want take my opinion into consideration.

So what HAVE you done to help your overweight child lose weight? Anything? Or is it all Mom's fault?

 

[checkyourmirror]

So what HAVE you done to help your overweight child lose weight? Anything? Or is it all Mom's fault?

I actually thought this was a legal advice forum.... She chooses to live with her mother and I have asked her to join programs like Weight Watchers, etc. I've offered to join them with her, walk with her, etc. She is 18 and lives with her mother because of the lack of structure and rules and I am putting the pressure on my Ex. The Lap Band is no silver bullet and I know people who have gotten one only to "fail" because they didn't follow the eating rules, etc. Since my daughter has not focused on any level of effort on weight loss, I believe she end up with problems even with the Band.

 

[ecmst12]

You are probably right about that, but hopefully the doctor that she goes to will emphesize this sufficiently for her to understand it.

I think your stronger argument is that your child has aged out of the support order and so you have no obligation to pay anything for her anymore.

 

[stealth2]

I actually thought this was a legal advice forum.... She chooses to live with her mother and I have asked her to join programs like Weight Watchers, etc. I've offered to join them with her, walk with her, etc. She is 18 and lives with her mother because of the lack of structure and rules and I am putting the pressure on my Ex. The Lap Band is no silver bullet and I know people who have gotten one only to "fail" because they didn't follow the eating rules, etc. Since my daughter has not focused on any level of effort on weight loss, I believe she end up with problems even with the Band.

The parenting input is a freebie.