Health insuranceplans provide coverage only for health-related services that they consider to be medically necessary.
to be covered under the health plan, a service must be considered medically necessary.
Keep in mind that “covered” doesn’t mean the health plan pays for it.
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But prior authorization is almost never needed with Original Medicare.)
Most health plans will not pay for healthcare services that they deem to be not medically necessary.
However,states determine the services plans must coverto comply with the essential health benefits requirements.
Prior authorization is often used to make this determination.
Medical Uses of Marijuana
The use ofmarijuana for medical reasonsis a prominent “medical necessity” case.
Medical marijuana first became legal under state statute with the passage of California’s Proposition 215 in 1996.
However, as a Schedule I drug under the Controlled Substance Act, marijuana is illegal under federal law.
The Department of Justice proposed a rule change in 2021 that would reclassify marijuana as a Schedule III drug.
As of mid-2024, however, marijuana is still a Schedule I drug.
The DEA also agreed in 2016 to increase the number of DEA-approved facilities growing marijuana for research purposes.
However, certain FDA-approvedsyntheticTHC can be included in a health insurance plan’s covered drug list.
If you are not sure, call your health plans customer service representative.
As touched on above, it’s also important to understand any rules your health plan may have regardingpre-authorization.
For certain expensive prescriptions, your health plan might have a step therapy protocol in place.
Summary
A service has to be deemed medically necessary to be covered by health insurance.
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