In Minnesota there is a statute which requires an "independent external medical review of adverse determinations" by an independent contractor at the expense of the government or of the health plan that denies medical benefits. It is key that the benefits are "medically necessary." See M.S.A. § 62Q.73, titled "Independent Review of Adverse Determinations."
"Medically necessary." That is also the standard for receiving medical benefits under Medicare.
The Minnesota Court of Appeals recently held that the statutory right to an "independent medical review" of "medical necessity" is a contract right held by the person who was denied the medical benefits in question. See Linn v. BCBSM, Inc., ___ N.W.2d ___, No. A16-0986, 2017 WL 393924, at *1 (Minn. Ct. App. January 30, 2017) ("Syllabus by the Court. The determination of medical necessity in an external-review process conducted under Minnesota Statutes section 62Q.73 (2016) is contractually binding on a health insurer.").
Arguably, so should a "medically necessary" benefit be a contract right under Medicare.1 "By a parity of reasoning," as they say.
Some would also say, by a parity of good judgment.
1As might be expected, the Minnesota State Statute expressly exempts Federal Medicare from its operation.
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