California health plans delegate most of the medical decision making to physician groups, although the plan retains final decision making authority. Only physicians are allowed to make denial decisions, however. Very few treatments are actually denied . The same case can result in different decisions to approve or deny, depending on the plan .
Every plan has a slightly different definition of medical necessity in contract .
Contractual definitions are so vague that decisions are instead based on guidelines, expert opinion, and medical directors' experience of what is necessary care. This produces variation that may not benefit the patient. If implemented consistently, best practices might improve the decision making process for consumers and providers of health care. The workshop produced over 35 recommendations for ways to improve the approval process for treatment authorization. Decision makers enthusiastically supported the adoption of a number of these recommendations, designed to address communication, consistency, and implementation deficiencies.