My claim was denied
The plan said "not medically necessary." What now?
Photo: Mikhail Nilov / Pexels
The plan's reviewer decided the care did not meet its rules for your diagnosis. That is a judgment, not a fact; ask for the rule they used and have your doctor answer it.
What to do
- Ask the plan in writing for the clinical criteria (the written rule) it used, and who reviewed the request.
- Send the denial and the criteria to your doctor and ask for a letter of medical necessity that answers each point, with records of what was tried first.
- Ask whether the plan offers a peer-to-peer review, a call between your doctor and the plan's doctor.
- File the internal appeal by the deadline on the letter, often 180 days, and ask for external review if the plan says no again.
What to say
Please send me the clinical criteria you used to decide this was not medically necessary, and tell me who reviewed it. What documentation would you need to approve it?
Ask in writing too, through the plan's portal or by mail, so there is a record of the request.
What to watch out for
This is a sensitive stepSmall details here can change the outcome, and some mistakes are hard to undo. We highly recommend a free 15-minute call with us before you decide.
Treating the letter as a medical opinion about you. The reviewer usually has not seen you; they compared paperwork to a rule, and paperwork can be added.
Better done together
We’re here to help
“Not medically necessary” is a judgment, and judgments can be questioned. We help you get the rule the plan used, compare it to the records, and work with the doctor's office on what the appeal needs.
Every situation is different, and these are sensitive moments, so we look at yours with care. We often see what others miss, and we never take commissions from insurance companies: the only thing we are working for is what is right for you.
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The rule behind it
Your plan's Evidence of Coverage defines medical necessity, and the plan uses its own clinical criteria to decide it. Federal appeal rules for most private plans let you get those criteria free, require someone new to decide the appeal, and let medical-judgment denials go to an independent external review. Since 2024, Medicare Advantage plans must follow Original Medicare's coverage rules.
Sources
- Cornell LII — 29 CFR 2560.503-1, claims and appeals rules
- Cornell LII — 45 CFR 147.136, internal appeals and external review
- HealthCare.gov — External review
- HealthCare.gov — Internal appeals
- CMS.gov — 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F)
Amanda Alcodia
Education, not medical, legal or insurance advice.
Useful next steps
Start with the free Kit. If your situation needs a person, the intro call is free too.