{"id":"https://openalex.org/W2007783083","doi":"https://doi.org/10.1056/nejm199901213400312","title":"Who Should Determine When Health Care is Medically Necessary?","display_name":"Who Should Determine When Health Care is Medically Necessary?","publication_year":1999,"publication_date":"1999-01-21","ids":{"openalex":"https://openalex.org/W2007783083","doi":"https://doi.org/10.1056/nejm199901213400312","mag":"2007783083","pmid":"https://pubmed.ncbi.nlm.nih.gov/9895406"},"language":"en","primary_location":{"id":"doi:10.1056/nejm199901213400312","doi":"https://doi.org/10.1056/nejm199901213400312","is_oa":false,"landing_page_url":"https://doi.org/10.1056/nejm199901213400312","pdf_url":null,"source":{"id":"https://openalex.org/S62468778","display_name":"New England Journal of Medicine","issn_l":"0028-4793","issn":["0028-4793","0096-6762","1533-4406","2331-4710"],"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["anvur-class-a","anvur-scientific","cwts-core","dongbi-a","doyens","jufo-3","ki-jl-3","medline","norway-2","poland-200","russia-white-list-1","vabb-shw"],"host_organization":"https://openalex.org/P4310320239","host_organization_name":"Massachusetts Medical Society","host_organization_lineage":["https://openalex.org/P4310320239"],"host_organization_lineage_names":["Massachusetts Medical Society"],"type":"journal"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"New England Journal of Medicine","raw_type":"journal-article"},"volume":null,"type":"editorial","is_traditional":true,"indexed_in":["crossref","pubmed"],"open_access":{"is_oa":false,"oa_status":"closed","oa_url":null,"any_repository_has_fulltext":false},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5070175822","display_name":"Sara E Rosenbaum","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I193531525","display_name":"George Washington University","ror":"https://ror.org/00y4zzh67","country_code":"US","type":"education","lineage":["https://openalex.org/I193531525"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"Sara Rosenbaum","raw_affiliation_strings":["George Washington University School of Public Health and Health Services, Washington, DC 20006, USA"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"George Washington University School of Public Health and Health Services, Washington, DC 20006, USA","institution_ids":["https://openalex.org/I193531525"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5085261068","display_name":"David M. Frankford","orcid":"https://orcid.org/0000-0002-8261-385X","observed_orcids":["https://orcid.org/0000-0002-8261-385X"]},"institutions":[{"id":"https://openalex.org/I193531525","display_name":"George Washington University","ror":"https://ror.org/00y4zzh67","country_code":"US","type":"education","lineage":["https://openalex.org/I193531525"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"David M. Frankford","raw_affiliation_strings":["george Washington University"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"george Washington University","institution_ids":["https://openalex.org/I193531525"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5082486553","display_name":"Brad B. Moore","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I193531525","display_name":"George Washington University","ror":"https://ror.org/00y4zzh67","country_code":"US","type":"education","lineage":["https://openalex.org/I193531525"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"Brad Moore","raw_affiliation_strings":["george Washington University"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"george Washington University","institution_ids":["https://openalex.org/I193531525"]}]},{"author_position":"last","author":{"id":"https://openalex.org/A5062330093","display_name":"Phyllis C. Borzi","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I193531525","display_name":"George Washington University","ror":"https://ror.org/00y4zzh67","country_code":"US","type":"education","lineage":["https://openalex.org/I193531525"]}],"countries":["US"],"is_corresponding":false,"raw_author_name":"Phyllis Borzi","raw_affiliation_strings":["george Washington University"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"george Washington University","institution_ids":["https://openalex.org/I193531525"]}]}],"institutions":[],"countries_distinct_count":1,"institutions_distinct_count":1,"corresponding_author_ids":[],"corresponding_institution_ids":["https://openalex.org/I193531525"],"apc_list":null,"apc_paid":null,"fwci":null,"has_fulltext":false,"cited_by_count":69,"citation_normalized_percentile":null,"cited_by_percentile_year":null,"biblio":{"volume":"340","issue":"3","first_page":"229","last_page":"232"},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T10391","display_name":"Healthcare Policy and Management","score":0.9922000169754028,"subfield":{"id":"https://openalex.org/subfields/2002","display_name":"Economics and Econometrics"},"field":{"id":"https://openalex.org/fields/20","display_name":"Economics, Econometrics and Finance"},"domain":{"id":"https://openalex.org/domains/2","display_name":"Social Sciences"}},"topics":[{"id":"https://openalex.org/T10391","display_name":"Healthcare Policy and Management","score":0.9922000169754028,"subfield":{"id":"https://openalex.org/subfields/2002","display_name":"Economics and Econometrics"},"field":{"id":"https://openalex.org/fields/20","display_name":"Economics, Econometrics and Finance"},"domain":{"id":"https://openalex.org/domains/2","display_name":"Social Sciences"}},{"id":"https://openalex.org/T11531","display_name":"Healthcare Systems and Reforms","score":0.0020000000949949026,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T13099","display_name":"Health, Medicine and Society","score":0.0017000000225380063,"subfield":{"id":"https://openalex.org/subfields/3600","display_name":"General Health Professions"},"field":{"id":"https://openalex.org/fields/36","display_name":"Health Professions"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/medical-necessity","display_name":"medical necessity","score":0.859000027179718},{"id":"https://openalex.org/keywords/health-insurance-coverage","display_name":"health insurance coverage","score":0.8360000252723694},{"id":"https://openalex.org/keywords/managed-care","display_name":"managed care","score":0.9070000052452087},{"id":"https://openalex.org/keywords/physician-autonomy","display_name":"physician autonomy","score":0.8809999823570251},{"id":"https://openalex.org/keywords/clinical-decision-making","display_name":"clinical decision-making","score":0.5649999976158142},{"id":"https://openalex.org/keywords/health-care-financing","display_name":"health care financing","score":0.3869999945163727}],"concepts":[{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.7069076299667358},{"id":"https://openalex.org/C160735492","wikidata":"https://www.wikidata.org/wiki/Q31207","display_name":"Health care","level":2,"score":0.5926873087882996},{"id":"https://openalex.org/C162118730","wikidata":"https://www.wikidata.org/wiki/Q1128453","display_name":"Actuarial science","level":1,"score":0.5590864419937134},{"id":"https://openalex.org/C2780265253","wikidata":"https://www.wikidata.org/wiki/Q1416012","display_name":"Managed care","level":3,"score":0.5475226640701294},{"id":"https://openalex.org/C65414064","wikidata":"https://www.wikidata.org/wiki/Q484105","display_name":"Autonomy","level":2,"score":0.5464864373207092},{"id":"https://openalex.org/C3018838755","wikidata":"https://www.wikidata.org/wiki/Q31207","display_name":"Medical care","level":2,"score":0.46887850761413574},{"id":"https://openalex.org/C2983635472","wikidata":"https://www.wikidata.org/wiki/Q334911","display_name":"Health insurance","level":3,"score":0.4435947835445404},{"id":"https://openalex.org/C545542383","wikidata":"https://www.wikidata.org/wiki/Q2751242","display_name":"Medical emergency","level":1,"score":0.34971728920936584},{"id":"https://openalex.org/C512399662","wikidata":"https://www.wikidata.org/wiki/Q3505712","display_name":"Family medicine","level":1,"score":0.29935896396636963},{"id":"https://openalex.org/C144133560","wikidata":"https://www.wikidata.org/wiki/Q4830453","display_name":"Business","level":0,"score":0.22057485580444336},{"id":"https://openalex.org/C199539241","wikidata":"https://www.wikidata.org/wiki/Q7748","display_name":"Law","level":1,"score":0.10070177912712097},{"id":"https://openalex.org/C162324750","wikidata":"https://www.wikidata.org/wiki/Q8134","display_name":"Economics","level":0,"score":0.09750491380691528},{"id":"https://openalex.org/C50522688","wikidata":"https://www.wikidata.org/wiki/Q189833","display_name":"Economic growth","level":1,"score":0.06798195838928223},{"id":"https://openalex.org/C17744445","wikidata":"https://www.wikidata.org/wiki/Q36442","display_name":"Political science","level":0,"score":0.0}],"mesh":[{"descriptor_ui":"D003657","descriptor_name":"Decision Making","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006301","descriptor_name":"Health Services Needs and Demand","qualifier_ui":"Q000331","qualifier_name":"legislation & jurisprudence","is_major_topic":false},{"descriptor_ui":"D006301","descriptor_name":"Health Services Needs and Demand","qualifier_ui":"Q000458","qualifier_name":"organization & administration","is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D007348","descriptor_name":"Insurance, Health","qualifier_ui":"Q000331","qualifier_name":"legislation & jurisprudence","is_major_topic":true},{"descriptor_ui":"D012945","descriptor_name":"Social Values","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D014481","descriptor_name":"United States","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D016079","descriptor_name":"Refusal to Treat","qualifier_ui":"Q000331","qualifier_name":"legislation & jurisprudence","is_major_topic":false},{"descriptor_ui":"D018166","descriptor_name":"Health Care Reform","qualifier_ui":"Q000331","qualifier_name":"legislation & jurisprudence","is_major_topic":false},{"descriptor_ui":"D019458","descriptor_name":"Insurance Coverage","qualifier_ui":"Q000331","qualifier_name":"legislation & jurisprudence","is_major_topic":false},{"descriptor_ui":"D019458","descriptor_name":"Insurance Coverage","qualifier_ui":"Q000458","qualifier_name":"organization & administration","is_major_topic":true},{"descriptor_ui":"D019461","descriptor_name":"Employee Retirement Income Security Act","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D032921","descriptor_name":"Consensus","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D032982","descriptor_name":"Contracts","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D036302","descriptor_name":"Therapeutic Human Experimentation","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false}],"locations_count":4,"locations":[{"id":"doi:10.1056/nejm199901213400312","doi":"https://doi.org/10.1056/nejm199901213400312","is_oa":false,"landing_page_url":"https://doi.org/10.1056/nejm199901213400312","pdf_url":null,"source":{"id":"https://openalex.org/S62468778","display_name":"New England Journal of Medicine","issn_l":"0028-4793","issn":["0028-4793","0096-6762","1533-4406","2331-4710"],"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["anvur-class-a","anvur-scientific","cwts-core","dongbi-a","doyens","jufo-3","ki-jl-3","medline","norway-2","poland-200","russia-white-list-1","vabb-shw"],"host_organization":"https://openalex.org/P4310320239","host_organization_name":"Massachusetts Medical Society","host_organization_lineage":["https://openalex.org/P4310320239"],"host_organization_lineage_names":["Massachusetts Medical Society"],"type":"journal"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"New England Journal of Medicine","raw_type":"journal-article"},{"id":"pmid:9895406","doi":null,"is_oa":false,"landing_page_url":"https://pubmed.ncbi.nlm.nih.gov/9895406","pdf_url":null,"source":{"id":"https://openalex.org/S4306525036","display_name":"PubMed","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I1299303238","host_organization_name":"National Institutes of Health","host_organization_lineage":["https://openalex.org/I1299303238"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"The New England journal of medicine","raw_type":"Journal Article"},{"id":"pmh:oai:repository.library.georgetown.edu:10822/1038304","doi":null,"is_oa":false,"landing_page_url":"http://hdl.handle.net/10822/1038304","pdf_url":null,"source":{"id":"https://openalex.org/S4306402467","display_name":"DigitalGeorgetown (Georgetown University Library)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I4210145449","host_organization_name":"Center for Security and Emerging Technology","host_organization_lineage":["https://openalex.org/I4210145449"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":"eweb:199683","raw_type":null},{"id":"pmh:oai:repository.library.georgetown.edu:10822/754804","doi":null,"is_oa":false,"landing_page_url":"http://worldcatlibraries.org/registry/gateway?version=1.0&url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&atitle=Who+Should+Determine+when+Health+Care+Is+Medically+Necessary?&title=New+England+Journal+of+Medicine.++&volume=340&issue=3&pages=229-232&date=1999&au=Rosenbaum,+Sara","pdf_url":null,"source":{"id":"https://openalex.org/S4306402467","display_name":"DigitalGeorgetown (Georgetown University Library)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I4210145449","host_organization_name":"Center for Security and Emerging Technology","host_organization_lineage":["https://openalex.org/I4210145449"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":"BRL:MEDKIE/99101873","raw_type":null}],"best_oa_location":null,"sustainable_development_goals":[{"display_name":"Good health and well-being","id":"https://metadata.un.org/sdg/3","score":0.4043000042438507}],"study_designs":[],"awards":[],"funders":[],"has_content":{"grobid_xml":false,"pdf":false},"content_urls":null,"referenced_works_count":7,"referenced_works":["https://openalex.org/W1571185656","https://openalex.org/W1975813256","https://openalex.org/W2009145937","https://openalex.org/W2016183530","https://openalex.org/W2026616556","https://openalex.org/W2078602301","https://openalex.org/W4301046946"],"related_works":["https://openalex.org/W3133008687","https://openalex.org/W3110704266","https://openalex.org/W2009145937","https://openalex.org/W2167233768","https://openalex.org/W2298506163","https://openalex.org/W2029242507","https://openalex.org/W107143638","https://openalex.org/W162639689","https://openalex.org/W1979857770","https://openalex.org/W2030129022"],"abstract_inverted_index":{"In":[0],"the":[1,11,27,30],"United":[2],"States":[3],"there":[4],"has":[5],"been":[6],"a":[7],"radical":[8],"shift":[9],"in":[10,87],"power":[12,91],"to":[13,94],"determine":[14,95],"when":[15],"health":[16],"care":[17,78],"is":[18,84],"medically":[19],"necessary":[20,76],"and":[21,39,64,79],"therefore":[22],"covered":[23],"by":[24,43,60],"insurance.":[25],"From":[26],"1950s":[28],"through":[29],"late":[31],"1970s,":[32],"physicians'":[33],"medical":[34,77],"opinions":[35],"largely":[36],"dictated":[37],"coverage":[38,83,96],"were":[40],"rarely":[41],"challenged":[42],"insurers.":[44],"Physicians":[45],"no":[46],"longer":[47],"have":[48],"this":[49],"extraordinary":[50],"level":[51],"of":[52,92],"autonomy.":[53],"Insurers":[54],"now":[55],"routinely":[56],"make":[57],"treatment":[58],"decisions":[59,74,80],"determining":[61],"what":[62],"goods":[63],"services":[65],"they":[66],"will":[67],"pay":[68],"for.":[69],"The":[70,90],"line":[71],"between":[72],"clinical":[73],"about":[75,81],"insurance":[82],"particularly":[85],"blurred":[86],"managed-care":[88],"plans.":[89],"insurers":[93],"potentially":[97],"gives":[98],"them":[99],".":[100,101,102]},"counts_by_year":[{"year":2023,"cited_by_count":1},{"year":2020,"cited_by_count":2},{"year":2018,"cited_by_count":1},{"year":2017,"cited_by_count":1},{"year":2016,"cited_by_count":1},{"year":2015,"cited_by_count":3},{"year":2013,"cited_by_count":1},{"year":2012,"cited_by_count":1}],"updated_date":"2026-11-04T10:54:05.112534","created_date":"2016-06-24T00:00:00"}
