PRP等醫療措施是否具醫療必要性之探討【本期企劃】 試閱
A Study on the Medical Necessity of PRP and Related Medical Interventions
近年因醫療科技進步，產生諸多新型醫療措施，而此等新型醫療措施之執行，是否為健康保險承保之範圍，於國內產生諸多爭議。其中重點在於，措施是否具醫療必要性或住院必要性？健康保險人應否就此等醫療措施支付保險金？就必要性之探討，國內學說及實務大致可分為三種見解：第一種為主治醫師標準說（主觀說），即以主治醫師之判斷為準；第二種為一般醫療標準說（客觀說），即以相同專科之醫師，於相同情形通常會診斷具有必要性者，方認為必要；第三種為折衷說，即原則尊重主治醫師的看法，但如顯然與醫療常規不符時，則以客觀的醫療常規為準。考察美國健康保險作業亦有相同之問題，本文簡略介紹該國就此爭議之若干討論，期能提供方向以供國內思考如何妥適解決此等問題。
In recent years, rapid advances in medical technology have facilitated the development of a wide range of novel medical interventions. Whether such interventions should be deemed compensable under health insurance schemes has consequently generated substantial controversy in Taiwan. At the core of these disputes lies the determination of whether a given intervention satisfies the requirements of “medical necessity” or “necessity of hospitalization,” and, accordingly, whether health insurers are legally obligated to provide insurance benefits therefor. With respect to the determination of medical necessity, Taiwanese legal scholarship and judicial practice may generally be classified into three principal approaches. The first is the “attending physician standard” (subjective approach), pursuant to which the professional judgment of the attending physician is accorded decisive weight. The second is the “general medical standard” (objective approach), under which medical necessity is recognized only where physicians within the same specialty would ordinarily consider the intervention necessary under analogous clinical circumstances. The third is an intermediate or hybrid approach, which, as a general matter, defers to the attending physician’s professional assessment, but adopts objective standards of accepted medical practice where such assessment is manifestly inconsistent with prevailing medical norms. Comparable controversies have likewise emerged in the administration and adjudication of health insurance claims in the United States. Accordingly, this article briefly examines selected discussions and doctrinal developments in American law concerning the determination of medical necessity, with a view to providing a comparative framework through which Taiwan may further contemplate the appropriate resolution of such disputes.
030-042
