What is your definition of health?

Why A Holistic Definition Of Health Is More Useful To Our Family

What is your definition of health? – It usually starts as an innocent question in an attempt to make friendly conversation with my husband, Jared, and me. What is your definition of health?

“So, how’s Jared? How’s his health?”

Those who ask this question are often aware that Jared has hemophilia B and a seizure disorder. But not everyone knows how these conditions affect him, much less how he manages them.

“Pretty stable,” I usually reply.

What having stable health means

“Stable” means nothing has really changed regarding Jared’s conditions. He still has bleeding episodes every month or so. He occasionally has seizures, especially on heavy emotional days. Thankfully, his current meds are much better at keeping attacks in check than the previous ones were.

Hemophilia is unpredictable by nature, making it impossible for us to know which body part will bleed next. The best we can do is be prepared for any possibility and learn to manage everyday life with temporary hiccups. This involves adjusting expectations and goals depending on Jared’s capacity on a particular day.

Sometimes Jared can do a lot. On a good day, he can lift 100-pound weights, prepare a three-course meal for our family, and work more than eight hours. But on a bad day, he might be confined to his bed, immobile for three days to a week and unable to concentrate on work. On those days, he plays hand-held games to distract from the pain of a bleed.

Stable is the best it can get

I’d hate to let anyone down, but having stable health is the best we can ask for. Unless a new treatment comes along to help him stay bleed-free for longer periods of time, he’ll likely continue to have bleeds every month.

Should prophylactic doses of factor finally become available — and affordable — in the Philippines, where we live, Jared might have a shot at enjoying a bleed-free year. But for now, that remains a pipe dream.

Monthly bleeds are his normal. They’re the baseline from which we gauge the state of his health.

As long as the frequency of his bleeds stays roughly the same and he doesn’t have the “bad” kind of bleeds more often, we see no reason to worry.

What is a more holistic definition of health?

In the past, health was equated to the absence of infirmity or disease. It’s a definition I personally find limiting, as it dismisses the subjective experience of people with chronic illnesses who don’t fall within this category but can still live happy and fulfilling lives with the aid of modern medicine.

In 1948, the World Health Organization proposed a definition of health as “a state of complete physical, mental, and social well-being, not merely the absence of infirmity or disease.” While some have criticized this definition as impractical, I agree with it.

Jared doesn’t check all three of those boxes daily, but he does like to tell me that, all things considered, he’s happy with his life. After all, being born with hemophilia means that he has no other life to compare his current one with. He’s never experienced the kind of life most people would call “healthy,” so he can’t know if it would be any better than the life he’s living now.

In some ways, I think Jared’s health is better than it used to be. He’s gotten much better at self-infusion, and I’ve seen his confidence levels rise because of it. Learning to treat himself has been liberating, as he no longer needs to depend on others for his treatment. He’s able to work full time, and he’s about to start a new business. He has a family that loves him and the support of good friends.

Holistically speaking, he might be doing quite well.

Note: Hemophilia News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Hemophilia News Today or its parent company, BioNews, and are intended to spark discussion about issues pertaining to hemophilia.

The Definition Of Medical Necessity In Health Insurance

Health insurance plans provide coverage only for health-related services that they consider to be medically necessary. This article will explain what medical necessity means and how health insurance plans determine whether a particular service is considered medically necessary.

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Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary to maintain or restore your health or to treat a diagnosed medical problem. In order to be covered under the health plan, a service must be considered medically necessary.

(Keep in mind that “covered” doesn’t mean the health plan pays for it. You still have to pay your required cost-sharing—copay, deductible, and/or coinsurance—before the health plan starts to pay any of the cost, even for covered services. And you’ll likely be responsible for at least some of the cost until you’ve met your health plan’s out-of-pocket maximum for the year.)

Medicare, for example, defines medically necessary as: “Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.”

Most health plans will not pay for healthcare services that they deem to be not medically necessary. The most common example is a cosmetic procedure, such as the injection of medications, such as Botox, to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental or not proven to work.

But “cosmetic” procedures done for restorative purposes are generally covered by health insurance, such as breast reconstruction after a mastectomy, plastic surgery after an injury, or repair of congenital defects such as cleft palate.

© Provided by Verywell Health PhotoAlto / Frederic Cirou / Getty Images Criteria to Determine Medical Necessity

Medicare and private insurers have varying criteria for determining whether a given procedure is medically necessary based on the patient’s circumstances. Medicare uses National Coverage Determinations and private Medicare plans (i.E., Medicare Advantage) use Local Coverage Determinations in order to ensure that the criteria for medical necessity are met.

Private insurers that offer non-Medicare plans can set their own criteria (which may or may not mirror Medicare’s criteria), although they’re required to provide coverage that’s in compliance with state and federal benefit mandates.

For individual and small group health plans with effective dates of January 2014 or later, this includes coverage for the essential health benefits defined by the Affordable Care Act. But states determine the exact standards plans have to meet in order to be in compliance with the essential health benefits requirements. So there is some state-to-state variation in terms of the specific services that are covered for each essential health benefit.

Medical Uses of Marijuana

The use of marijuana for medical reasons is a prominent ‘medical necessity’ case. Cannabis is a plant with active ingredients that are widely reported by sufferers to be effective in pain control for various conditions, usually neuropathic in nature, where common pharmaceutical painkillers have not worked well.

Medical marijuana first became legal under state statute with the passage of California’s Proposition 215 in 1996. As of 2022, the medical use of cannabis is legal in 37 states and the District of Columbia, as well as three of the five U.S. Territories.

However, as a Schedule I drug under the Controlled Substance Act, marijuana is illegal under federal law. Schedule I drugs are defined by the Drug Enforcement Administration as having “no currently accepted medical use and a high potential for abuse.”

(Interestingly, cocaine and methamphetamine are both classified as Schedule II drugs, putting them one rung lower on the DEA’s system for classifying “acceptable medical use and the drug’s abuse or dependency potential.”)

Marijuana has also not been approved by the FDA, in part because its Schedule 1 classification has made it difficult for the FDA to conduct adequate trials to determine safety and efficacy. Over the last four decades, there have been repeated proposals to change the Schedule 1 classification for marijuana. And although the DEA has thus far refused to change the classification of marijuana, the agency did downgrade certain FDA-approved CBD products (with THC content below 0.1%) from Schedule 1 to Schedule 5 in 2018.

The DEA also agreed in 2016 to increase the number of DEA-approved facilities growing marijuana for research purposes. (For decades, there had only been one such facility, at the University of Mississippi, with the product only used for research by the National Institute on Drug Abuse.) The DEA noted in 2019 that they were “making progress in the program to register additional marijuana growers for federally authorized research, and will work with other relevant federal agencies to expedite the necessary next steps.”

In 2021, the DEA indicated that “a number of [additional] manufacturers’ applications to cultivate marijuana for research needs in the United States appears to be consistent with applicable legal standards and relevant laws,” and that the DEA was continuing the process of working with those manufacturers to complete the approval process.

For the time being, however, due to marijuana’s classification as a Schedule I drug (with “no currently accepted medical use”), its illegality under federal laws, and the lack of any FDA approval, health insurance plans do not cover medical marijuana, regardless of whether state law deems it legal, and regardless of whether a healthcare provider deems it medically necessary. But certain FDA-approved synthetic THC can be included in a health insurance plan’s covered drug list.

Prior Authorization, Referrals, and Network Rules: Check With Your Health Plan

It’s important to remember that what you or your healthcare provider defines as medically necessary may not be consistent with your health plan’s coverage rules. Before you have any procedure, especially one that is potentially expensive, review your benefits handbook to make sure it is covered. If you are not sure, call your health plan’s customer service representative.

It’s also important to understand any rules your health plan may have regarding pre-authorization. Your plan might require you and your healthcare provider to get approval from the health plan before a non-emergency procedure is performed—even if it’s considered medically necessary and is covered by the plan—or else the plan can deny the claim.

And depending on your health plan’s rules, you may have to obtain a referral from your primary care healthcare provider and/or receive your treatment from a medical provider within the health plan’s network. If you don’t follow the rules your plan has in place, they can deny the claim even if the treatment is medically necessary.

For certain expensive prescriptions, your health plan might have a step therapy protocol in place. This would mean that you have to try lower-cost medications first, and the health plan would only pay for the more expensive drug if and when the other options don’t work.

Understand Your Right to Appeal

Health plans have appeals processes (made more robust under the Affordable Care Act) that allow patients and their healthcare providers to appeal when a pre-authorization request is rejected or a claim is denied.

While there’s no guarantee that the appeal will be successful, the ACA guarantees your right to an external review if your appeal isn’t successful via your health insurer’s internal review process, assuming you don’t have a grandfathered health plan.

Even if you do have a grandfathered plan, you have the right to an external appeal if the insurer’s adverse decision (ie, claim or prior authorization denial) is for a scenario that falls under the scope of the No Surprises Act. (ie, an out-of-network provider sending a balance bill for emergency care or services that were provided at an in-network facility.)

Summary

A service has to be deemed medically necessary in order to be covered by health insurance. Health plans use various guidelines, including state and federal benefit mandates, and case management procedures, to determine what services are considered medically necessary.

Even if a service is medically necessary, the patient may have to pay for some or all of the cost due to copays, deductibles, and coinsurance. And the patient may have to pay for a medically necessary service if the health plan’s rules for prior authorization or step therapy are not followed.

A Word From Verywell

In most cases, the medical care that your doctor recommends will be considered medically necessary by your health plan. But to avoid surprise medical bills, it’s wise to be sure you’re following all of the procedures your health plan has in place, including things like obtaining prior authorization, staying in-network, and following step therapy rules, if applicable. It’s always better to check first with your health insurance plan, as opposed to assuming that a particular service will be covered.

Kaleidoscopic Image Of A Mouse’s Brain Is 64 Million Times Sharper Than A Typical MRI

powerful MRI merged with light-sheet microscopy allows researchers to create a high-definition wiring diagram of the entire brain in mice.

Scientists recently boosted the resolution of magnetic resonance imaging (MRI) to 64 million times higher than normal. They used the technique to take captivating, high-definition images of a mouse brain, showing the organ like never before.

While the swirly, psychedelic images are that of a rodent’s brain, the research team thinks humans could be next to undergo one of these newly enhanced brain scans. The technology could help doctors detect changes to the human brain that occur due to neurodegenerative diseases, such as Alzheimer’s disease, as well as changes linked to healthy aging.

The mouse scan was shared as part of a new paper published April 17 in the journal PNAS.

“It is something that is truly enabling,” lead author G. Allan Johnson, a distinguished professor of radiology at Duke University, said in a statement. “We can start looking at neurodegenerative diseases in an entirely different way.”

Related: First-ever scan of a dying human brain reveals life may actually ‘flash before your eyes’

For four decades, Johnson, with the help of a revolving team of students and researchers from Duke University’s Center for In Vivo Microscopy, has been working on improving MRI, which was invented by American physician Dr. Raymond Damadian 50 years ago.

MRI uses powerful magnets to generate magnetic fields, which cause the hydrogen atoms within water molecules in the body to align their “spins,” or point in a specific direction. The machine then uses a pulse of radio waves to “flip” the atoms’ spins. The atoms then fall back into alignment, and each flip generates a radio signal that can be detected by the MRI scanner and used to make an image.

To improve upon this technology, researchers created a souped-up MRI outfitted with a high-powered 9.4-tesla magnet. (For comparison, most MRIs are equipped with a 1.5- to 3-tesla magnet.) They also added gradient coils that are 100 times stronger than current models and are what create the images, as well as a high-speed computer that is as powerful as approximately 800 laptops, according to the statement.

After scanning the mouse brain, the researchers sent tissue samples to be imaged using a technique called light sheet microscopy, which allowed them to label specific groups of cells in the brain that were then mapped onto the original MRI. These additional steps provided a colorful view of cells and circuits throughout the brain, according to the statement.

The researchers took one set of MRI images that captured how the mouse’s brain-wide connectivity evolved with age. A second group of images showcased brilliantly colored brain connections that highlighted the deterioration of neural networks in a rodent model of Alzheimer’s disease, according to the statement.

By studying mouse models of human diseases like Alzheimer’s, researchers can better understand how these conditions emerge and progress in humans. The technique could also be useful for studying how the brain changes when mice are put on specific diets or given drugs in an effort to extend their life spans, Johnson said in the statement.

“The question is, is their brain still intact during this extended lifespan?” he said. “We have the capacity now to look at it. And as we do so, we can translate that directly into the human condition.”