Medical Necessity in Private Health Plans

Figure 5: Medical Necessity Utilization Review and Appeals Procedures

Issue	ERISA	FEHBP
Standards for initial utilization review process	X
Standards for internal appeals of initial denials	X
Timelines	X	X
Qualifications of reviewer	X
De novo review	X
Evidentiary standards	X
Access by claimant to health plan evidence	X
Treatment guidelines	X
Definition of medical necessity
External de novo administrative review of health plan decision