My claim was denied
How do I get a letter of medical necessity?
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It is a letter from your doctor explaining why you need this specific care, written in the plan's own terms. Ask the doctor's office for it and give them the denial letter so they can answer the exact reason.
What to do
- Ask the doctor's office for a letter of medical necessity for an insurance appeal, and give them the denial letter.
- Ask that the letter answer the plan's reason point by point: diagnosis, what was tried before, why this care is needed now, and what may happen without it.
- Check that it names the service and billing codes exactly as the denial does.
- Read the letter before it is sent, and ask the office specific questions about anything that is missing or unclear.
- Send it with your appeal and keep a copy for the next step.
What to say
I'm appealing a denial and I need a letter of medical necessity from the doctor. Here is the denial letter with the plan's reason. Can the letter answer that reason directly?
Offices get many of these requests; a clear ask and the denial letter in hand make it faster.
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.
Assuming the letter is right because a doctor wrote it. Sometimes the codes or the wording don't match what the plan needs. That is usually nobody's fault; doctors and billing offices are busy, and every plan words its rules a little differently. A short, general letter that says the patient needs this, without answering the plan's reason, is the most common gap.
Better done together
We’re here to help
We read letters of medical necessity side by side with the denial and the plan's criteria, and help you ask the office for specific changes. What a letter needs depends on the insurance and the diagnosis, so it is worth a second look before it goes out.
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.
Free · 15 minutes · No pressure
The rule behind it
A letter of medical necessity isn't a special legal form; it is your doctor's evidence for your appeal. Plans judge medical necessity by their own clinical criteria, and federal appeal rules for most private plans let you get those criteria free on request. The appeal must consider everything you send and be decided by someone who did not make the first decision.
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 — Internal appeals
- Your denial letter
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.