Who Decides What Is Medically Necessary

"Medically necessary" sounds technical, but it controls everything. If a service counts as medically necessary, it is in. If it does not, you pay or you go without. That is true today. The difference is who holds the pen.

Right now the pen sits in a lot of private offices. Hundreds of insurers and employer plans write their own definitions and rule books. One plan says the MRI is covered. Another says you should try physical therapy first. A third says no because you did not check the right box last year. Appeal rights change every time you change jobs or your employer changes carriers. None of that is democratic or transparent.

SAFECARE admits the hard truth. Someone will always have to decide what counts as essential care. There is no way around that. The question is whether those decisions are made in private, driven by profit and scattered across dozens of companies, or made in public, driven by clinical standards and subject to one set of appeals.

SAFECARE uses a national standard that is written into law and refined by an independent clinical board, not a political "death panel". The definition combines three things.

• Evidence based guidelines: What does the best available medical evidence say about this treatment for this condition.
• Professional practice: What do front line doctors and nurses actually use as standard of care for this problem in real life.
• Patient circumstances: Does this person have conditions or risks that make a given test or treatment especially important or especially dangerous.

The clinical board includes physicians, nurses, pharmacists, patient representatives and health economists. It holds public meetings, publishes its criteria and updates them on a regular schedule. When it changes coverage rules, it has to explain why. That is very different from a private carrier quietly changing internal policies mid year.

A single payer can abuse power if there are no checks. A fragmented payer landscape abuses people in a different way. It buries them in fine print and makes them fight the same battle over and over.

SAFECARE sets one baseline standard for the whole country. That has three concrete advantages.

• Clarity: Patients and clinicians know the rules. If a treatment is in the SAFECARE medical necessity standard for a condition, it is covered everywhere for that indication.
• Accountability: If Congress or the public dislike a coverage rule, they know exactly where to aim pressure. You can change the statute or push the board to revise its criteria. You do not have to chase fifty companies and a thousand employer plans.
• Consistency: A teacher, a truck driver and a small business owner do not get three different answers to the same medical question just because their cards have different logos.

SAFECARE builds a uniform appeals process. The steps are always the same.

• First, the treating clinician can submit additional information and request a reconsideration. That has to be reviewed within a clear time frame.
• If that fails, the patient can appeal to an independent review unit that is not paid by denying claims. Those reviewers must apply the national medical necessity standard and explain their reasoning in writing.
• If the case still looks wrong, there is a path to external review or court in serious disputes. One law. One standard. One appeals ladder. Not a new maze every time someone changes jobs.

In theory any system can be abused. The difference is how visible the abuse would be.

If SAFECARE suddenly declared that common cancer drugs or basic mental health care were "not medically necessary", that would show up on national statistics and in millions of lives at once. There would be hearings, headlines and elections. A single public standard is a big target. That is a feature, not a bug.

Private insurers already narrow coverage quietly through contract language, network games and prior authorization rules that most people never see until they are sick. There is no national vote on that. There is no simple way to fix it. You can appeal one case. You cannot easily change the rule.

Someone will always decide what is medically necessary. Under SAFECARE that decision is:

• based on evidence and standard clinical practice
• written in public by a named body, not a hidden "death panel"
• applied the same way across the country
• and open to one clear appeal ladder

That is a cleaner and more democratic way to draw the line than a private system that uses the same phrase while changing the meaning for every employer and every product.