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When Courts Review Medical Appropriateness

Anderson, Gerard PhD*; Hall, Mark A. JD; Smith, Teresa Rust MA

Original Articles

Objectives. The authors examined how the courts have responded to public and private insurers' use of medical appropriateness criteria to establish coverage and payment policies.

Methods. A structured review of all federal and state court health insurance cases decided between 1960 and June 1994 that involved a dispute involving medical appropriateness was performed. A total of 3,215 published court decisions were analyzed, of which 203 met the criteria of relevance and 124 explicitly mentioned medical appropriateness criteria. The main outcome variable was whether the court ordered the insurer to provide coverage.

Results. In 185 cases, a definitive decision was rendered, and the insurer was required to pay in 57% of the decisions. Whether the insurer relied on an assessment or not, whether the assessment process was formal or informal, and who conducted the assessment did not appear to influence courts' decisions, nor did the specificity of the coverage exclusion. Significant predictors of courts ordering coverage were court jurisdiction, contract language assigning discretion to the insurer, severity of patient's condition, and whether the treatment appeared to work for the particular patient.

Conclusions. For practice guidelines to be accepted by the courts, it is more important to focus on how insurance contracts are written than on how medical assessments are performed.

*From the Department of Health Policy and Management, Medicine, and International Health, Johns Hopkins University, Baltimore, Maryland.

From the Department of Law and Public Health, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina.

‡From the Department of Sociology, Bowman School of Medicine, Wake Forest University, Winston-Salem, North Carolina.

Supported in part by grant # 1 RO1 HS08681-01 from the Agency for Health Care Policy and Research.

Address correspondence to: Gerard F. Anderson, PhD, Center for Hospital Finance and Management, 624 N. Broadway #304, Baltimore, MD 21205.

© Lippincott-Raven Publishers