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.