https://healthlaw.org/wp-content/uploads/2025/11/Vanneman_Pr...
The overall situation is that the insurance company doesn't want to trust your doctor's judgement [0], so they insist on getting a second opinion about the care you might need to receive. That second opinion is still being performed by a licensed doctor who is supposed to be working in your interests - it's a straightforward practice of medicine the same as if you yourself were to go and seek out a second opinion.
[0] or really they want to play good cop / bad cop - remember "your" doctor themselves is essentially also an employee of the insurance company!
Feels like convenient lawcraft to wash the health plan employee’s hands of liability. I’m sure the prevailing popular opinion would be that this is practicing medicine.
Although on the words having meanings front, whatever is going on here is pretty clearly not insurance at this point; it'd be better just to honestly call it welfare rather than force people to redefine the word 'insurance'. It is hard to talk to people in the US about actual insurance now because they don't have a word for it any more. Politically redefining 'medicine' too would be a mistake, important conversations will become incoherent.
If I build you a house and tell you the roof trusses aren’t necessary, you’d be pretty peeved.
Maybe an even better analogy is that I live in a rented home and after I report some weird respiratory issues, an inspector finds black mold all over the place. The landlord refuses to fix the issue because "black mold is totally fine, bro" and I get really sick. I could maybe have moved out, but I kinda feel like the landlord is going to have a bad time here.
The issue with teeray's original comment is that they are saying someone who isn't practising medicine should be considered to be a medical practitioner. In fact, in this context, teeray is annoyed with them specifically because they didn't practice anything. Your analogy became irrelevant the moment it involved you doing anything.
> “X is or is not medically necessary” seems like a decision a medical professional should determine, no?
No, that is ridiculous. If I think I need to go to a hospital I'm going to go to the hospital. I don't need qualifications to work out something is medically necessary. I'm unlikely to be involved with the medical industry at all unless I've already personally determined it is medically necessary that I consult a doctor.
As a rule of thumb, patients have the final word on what they actually consider necessary. Literally anyone can have an opinion on the subject. Like, for example, an insurance worker. If the patient or the doctor is of a different opinion then they can go pay for the work themselves. It isn't that uncommon to have to go through 3 or 4 medical professionals to find one who agrees that work is necessary; I have a cancer story like that in my family.
This doesn't make any sense. They're not handing over money for fun, they are supposed to pay for the medical services the insurance is supposed to cover. And the only person qualified to decide if that medical service is appropriate is a doctor who specializes in the field of that specific area.
That might not be actually an option. Well the provider can do it for free, probably; but they may not be able to accept money for care that was denied coverage. A Medicare provider can charge patients for things outside the scope of Medicare, but generally can't charge for things in scope but deemed not medically necessary: ex if Medicare says 6 PT visits for whatever and you would like to have 8, you can't pay the provider for two more; you'd have to find a non medicare provider or come back with a fake moustache.
The reality is that this is the insurance companies trying to have their cake and eat it too. They actually want to be making a medical decision in denying coverage since it gives them a legitimate reason to do so, but want to avoid any liability if that decision was wrong.