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 non-covered 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 non-covered 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.