“Not medically necessary” denial: how to appeal

A common reason for denials

When a letter says a service was “not medically necessary,” the insurer is saying the care did not meet its standard for your situation. That is a judgment, and you can challenge it.

What the term means

HealthCare.gov defines medically necessary care as services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms that meet accepted standards of medicine. Insurers use their own written criteria to apply that idea, and those criteria can be narrower than what your doctor thinks is right for you.

How to respond

Get the criteria. Ask the insurer in writing which guideline or policy it used and for the documents in your claim file.
Involve your doctor. Ask for a letter covering your diagnosis, what you tried before, why this care is needed now, and what is likely to happen without it. Ask whether a doctor-to-doctor review with the insurer is available.
Add your records. Include test results, notes and the dates that support the request.
File on time. Under HealthCare.gov rules the internal appeal window is generally 180 days from the denial notice.

If the appeal is denied

Denials that involve medical judgment can usually go to an independent external review. You generally have 4 months to ask, and the insurer must accept the reviewer's decision. See how to appeal a denial for the steps.

Want help writing your letter?
Upload your denial letter, explanation of benefits or bill to MyMedReply. It writes your appeal or dispute and cites the rules that usually apply. The draft is free; you pay only to copy it.
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Sources

This guide is general information, not medical, legal or insurance advice. Rules and deadlines vary by plan and state, so your denial letter and plan documents control. Medicare and Medicaid have their own appeal rules.