Determining "Medical Necessity" in Mental Health Practice

. . . In previous work on home care and in vitro fertilization we have that determinations of medical necessity often rest on a range of moral as well as clinical facts. This paper reports the results of a of difficult insurance coverage decisions brought to us by mental health and reviewers in a managed care setting. We explored these cases the involved personnel by applying elements of the Socratic approach -- the clinician's (or reviewer's) considered views, varying crucial of the case, and examining the effects on their reasoning about necessity. This process revealed a recurrent conflict between what we "hardline" and "expansive" views of medical necessity. Although this often surfaces as disagreement about medical facts and diagnosis, we that it frequently reflects unrecognized moral disagreement about the of clinical intervention and the ultimate goals of psychiatric. In six case studies we examine the reasoning behind the of medical necessity. In the discussion we present three models defining medical necessity that can be discerned in the clinical, and propose what we regard as a defensible rationale for how the of medical necessity can be used in the administration of health benefits.