Thus, no deference to Blue Shield's decision is warranted. These decisions demonstrate a willingness of Pennsylvania's appellate courts to judge insurers' treatment decisions in an objective manner, rather than lending any credence or deference to the insurer's decision about, or interpretation of, its definition of medical necessity. Physicians' Access to the Legal System Physicians can access the legal system to challenge a Blue Shield medical necessity denial in three ways. They each relate to the amount of money at issue in the claim. A compulsory arbitration claim is heard by three local attorneys.
Evidentiary rules are relaxed.
The hearings on medical necessity claims typically take only an hour or two. Claims in excess of the county's jurisdictional limit should be handled by legal counsel. Regardless of the forum selected and the amount at issue, DJs, arbitrators and judges are swayed heavily by the patient's testimony and the physician's documentation. Experience teaches that reasonable disputes about medical necessity should not result in a bad faith claim. Much valuable time and legal resources can be wasted asserting a bad faith claim through numerous pretrial motions and protracted discovery.