:: HealthNet’s Benefit Denial Based Upon Lack Of Medical Necessity Rejected

he district court concluded that a remand was futile because the Wieners did not show that Jonathan was eligible for GHT under the standards described in IPRO’s decision, which the parties call “the FDA standard.”

It is unclear whether the FDA standard defines what is “medically necessary” under the policy. The policy provides, inter alia, that “medically necessary” treatment is that “within the standards of good medical practice with the organized medical community.” This definition does not refer to the FDA standard nor identify that standard as the yardstick of “good medical practice.”

Wiener v. Health Net of Conn., Inc., 2009 U.S. App. LEXIS 3542 (2d Cir. Conn. Feb. 23, 2009) (unpublished)

In an unpublished opinion, a Second Circuit panel found HealthNet’s benefit denial for lack of medical necessity unsupported by the record before the Court. Often a source of contention in benefit denial cases, the standards necessary to show medical necessity often fall short of an objective metric