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Glossary entry

English term or phrase:

appropriateness

English answer:

appropriateness

Added to glossary by María Eugenia Wachtendorff
May 17, 2009 14:51
14 yrs ago
5 viewers *
English term

appropriateness

English Medical Insurance Dental Insurance Plan
Grievance:
A written request by a member, or a provider acting on the member?s behalf and with the appropriate written consent of the member, to have the Insurance Company or a certified external review organization review the denial of reimbursement for a health care service where the denial was based on lack of medical necessity and appropriateness.

I am translating into Spanish and I think the term "appropriateness" has an ethical connotation in this particular context, but I would like to have your valuable opinions.

Thanks in advance!
Responses
4 +3 appropriateness
4 +1 customary and reasonable - appropriate considering the alternatives
3 covered by the policy

Discussion

María Eugenia Wachtendorff (asker) May 18, 2009:
Thank you, dear colleagues! All answers have been very useful :)
conejo May 18, 2009:
Appropriateness I agree with Mediamatrix's answer. In reading this, the sense that I get is that the "appropriateness" of a certain treatment or procedure is something objective that would be judged by medical professionals (probably different ones than denied the coverage). For example, let's say that the child's parents wanted a certain procedure, and asked the doctor to perform a procedure. There was nothing wrong exactly with performing the procedure, but maybe it was not exactly the typical procedure that would be done in that case. Then, if the insurance denied it, the parents might file a grievance with the insurance company, saying why won't you pay? Then other medical professionals would probably review it and see if it was "medically necessary" and if it was "appropriate". Which, if it wasn't medically necessary the doctor probably wouldn't have done it. But as some others have said, "appropriateness" is highly subjective, and the insurance may only cover 1 standard procedure for each medical issue. So, it's a very subjective topic. I do not feel however, that it has anything to do with anyone being unethical, or at least not from the context provided. Hope this helps!

Responses

+3
48 mins
Selected

appropriateness

My reading is that 'medical necessity' would refer to objective, technical criteria used to decide whether a medical act should be done to improve, or preserve, the patient's life. For example, if a patient has gangrene then it could be a 'medical necessity' to amputate that person's leg.

However, in that same example, it may not be appropriate to amputate, despite the medical 'necesity', if wider the context - including subjective considerations - are also taken into account. For example, if the patient is in any case going to die within 48 hours from some other medical condition, then it might not be 'appropriate' to amputate.
So, 'appropriateness' brings into the decision other factors besides mere medical technicalities. Depending on the patient (and the country where the treatment is carried out) those factors might include: religious beliefs, medical ethics, age and/or sex of the patient, general state of health of the patient, availability of the necessary medical skills to carry out the 'necesary' medical act successfully.

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Note added at 2 hrs (2009-05-17 17:37:14 GMT)
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A lot depends here on whether or not the adjective 'medical' is intended to - or actually does - qualify both 'necesity' [i]and[/i] 'appropriateness'. I suspect that this ambiguity - coupled with the use of 'and' rather than 'or' - has been carefully crafted into the definition to ensure that the client can always be proved to be wrong.
Note from asker:
Well, my translation is for the Spanish-speaking population in the U.S. and the subject is a Dental Insurance Plan for Children, with very limited coverage. They are defining "grievance," before explaining the Complaint & Grievance Procedures, and I am almost sure that "lack of medical necessity AND (not 'or') appropriateness" implies unethical behavior on the part of the dentist or the child’s parents, hence the "grievance". But never mind, I just decided to throw my OCD out the window and complete this job before the weekend is over. Thank you very much, Mediamatrix. I’ll follow your advice :)
Peer comment(s):
agree Tina Vonhof (X) : The treatment must conform to accepted medical practice given the symptoms and situation of the patient.
53 mins
agree Charlesp
13 hrs
agree conejo : I have more to say about this, and will post it in the discussion board
22 hrs
Something went wrong...
4 KudoZ points awarded for this answer. Comment: "Thanks a bunch!"
31 mins

covered by the policy

I cannot think of a specific insurance usage of the term. I think here it means simply that the reimbursement was denied because the treatment was not deemed to be covered by the policy.

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Note added at 55 mins (2009-05-17 15:47:03 GMT)
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Hi Maria,
I do not get a particular sense of potential fraudulent intent from your source text. The claim may be inappropriate because of simple ignorance of what the policy will cover (cosmetic work, for example).
Example sentence:

It is essential to take out an appropriate travel insurance policy before travelling

Reference:

http://www.pinnt.com/downloads/talking_points_02.pdf

Note from asker:
Hello, Samantha. I think your example sentence does not address the issue. Here, "the lack of medical necessity and appropriateness" is the reason for denial of reimbursement, i.e., the insurer is questioning the treatement as unnecessary and subtly pointing at potential fraudulent intent.
Ay, Samantha! It is exactly because cosmetic treatment is not covered that I started thinking of "lack of appropriateness" as synonymous to "unethical behavior". The definition I posted is the introduction to the Complaint & Grievance Procedure... But I give up! I'll take the term at face value and hope for the best. Thank you very much for your time and patience :)
Something went wrong...
+1
14 hrs

customary and reasonable - appropriate considering the alternatives

I don't think that they are necessariy referring in this context to an ethical issue, but rather to a financial one.

I think what is meant here by "appropriateness" is is the treatment or procedure appropriate for the particular illness/injury, including meaning are there less costly procedures or treatments available.

It might also exclude expermental treatment with unproven results.\

But in general I think it means 'what a reasonable man would do in the ordinary case simular to this particular one' (ie a legal definition, and "man" here not being a male person, but rather an individual or institution (the actor)). Or stated another way, what is customary and reasonable.

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Note added at 14 hrs (2009-05-18 05:34:18 GMT)
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Thanks.
Note from asker:
Thank you very much, Charles. You are right, elsewhere in the document there is a note about experimental treatments not being covered. And I like "customary and reasonable"!
Peer comment(s):
agree Samantha Payn
3 hrs
Something went wrong...
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