Denial determinations
based on coverage limitations contained in 32 CFR 199, the TRICARE Policy
Manual (TPM), and other TRICARE guidance, are considered factual
determinations. If it is determined that a service or supply is
covered, but is not medically necessary, is at an inappropriate level
of care, is custodial care, or other reasons relative to reasonableness,
necessity or appropriateness, the denial will be a medical necessity
determination under
Section 4 (see Example 1). The following are examples
of denials based on coverage limitations:
Example 1: A woman received an abortion and although
the services were found to be medically necessary (i.e., generally
accepted by qualified professionals to be reasonable and adequate
for the treatment of her condition), the coverage criteria set forth
in the TPM were not met. Although the care was determined to be
medically necessary, since the coverage criteria were not met, benefits
must be disallowed and appeal rights offered under this section.
(Note: If the facts were reversed such that coverage criteria were
met but the care was found not to be medically necessary, benefits
would be disallowed and appeal rights offered under the
Section 4.)
Example 2: Payment is denied for surgical evacuation
of hematomas following removal of breast implants from a previous
noncovered augmentation mammoplasty because the beneficiary’s hematomas
do not constitute a separate medical condition under
32 CFR 199.4(e)(9). Removal of the hematomas
is medically necessary, but the denial is based on a coverage limitation
because the complication is not a separate medical condition from
the noncovered augmentation mammoplasty. This is an example of a
case where medical review may be required to determine whether regulation
or policy criteria are met. Notwithstanding the necessity for involvement
of a medical reviewer, because the denial is based on a coverage
limitation, a factual determination results that is appealable to
a formal review conducted by the Defense Health Agency (DHA) Appeals and
Hearings Division.