The Department of Justice (DOJ) continues to make medical necessity a focal point of False Claims Act (FCA) enforcement. The DOJ explicitly identified medically unnecessary care as one of three major healthcare FCA enforcement priorities (alongside managed care and prescription drugs) in its January 16, 2026 announcement of record-breaking FY 2025 recoveries. Recent settlements underscore that the government remains vigilant in pursuing claims against providers who the government believes have billed federal healthcare programs for services deemed excessive, unnecessary, or unsupported by adequate documentation. Fraud allegations involving medical necessity issues are factually intense and complex, often requiring plaintiff and defense retention of respective “dueling” clinical experts. Medical-necessity cases are often fact-intensive, clinically nuanced, and expert-driven. They rarely turn on a single chart note or a simple disagreement between physicians; instead, they typically
