Not medically necessary

What it means

Your plan has decided that the care is not “medically necessary”. That is the plan’s own test, written in your plan document, for whether care fits your condition. It is a judgment about your medical situation, not a rule that excludes the service. That helps you: the plan must apply its test to you, and a doctor can answer with facts.

The denial notice must give the specific reasons and the plan rules it relied on. For a medical necessity denial it must either explain the clinical judgment as applied to your circumstances, or say the explanation is free on request.

Who has to act first

You and your treating doctor, with different jobs.

• You: ask the plan in writing for the claim file and criteria, and file the appeal on time. For a job-based plan or non-grandfathered individual plan, you have at least 180 days after you receive the notice (check the date on your notice, which controls). Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines.
• Your doctor: explains why this care is right for you, can ask for a peer-to-peer call (a doctor-to-doctor conversation with the plan’s reviewing physician), and writes the letter. If your provider appeals for you, you may need to sign a form naming them as your representative.

If waiting could seriously harm your health, a doctor who knows your condition can say the claim is urgent. The plan must then decide within 72 hours.

Arguments that work

• Use the plan’s own definition. Find “medically necessary” in your plan document and show how your records meet it, point by point.
• Use the plan’s own criteria. If the notice used an internal guideline, it must set it out or say a copy is free on request. Show which criteria your records meet, and say why any other does not fit you.
• A vague reason is a gap. A non-grandfathered plan must describe the standard it used, and its final internal denial must discuss the decision, not just give a code. Ask for both in writing.
• Make the reviewer read everything. The reviewer must consider all the records you send, including material the first decision never saw. On appeal the reviewer must be someone other than the first decision-maker, and must consult a health care professional with training in the field. You can ask who advised the plan.
• Cite guidelines. The independent reviewer weighs your records, your doctor’s recommendation, the plan terms and evidence-based practice guidelines. Ask your doctor to name one.
• Medicare Advantage. The plan must follow Original Medicare’s coverage rules and take your history and your doctor’s recommendations into account.
• Mental health or substance use care. The plan must give you its criteria on request. See the mental health parity guide.

Evidence to gather

• The denial notice and Explanation of Benefits (EOB) (you).
• The claim file, the criteria, and the names of any experts consulted (the plan, free on request).
• The plan’s definition of medical necessity (plan document, the plan’s website, or your employer’s benefits office).
• Medical records, test results and treatment history (your provider; ask early, as a records request can take 30 days, or up to 60 if the provider extends it).
• A letter from your doctor: diagnosis, what has been tried, why this care, and what is likely without it (your doctor).
• Your own short account of how the condition affects daily life (you).

What to send

Send one packet to the address in the denial notice, by a method that proves delivery: an appeal letter naming the claim and the stated reason, your doctor’s letter, the records, and a short list showing how they answer each criterion. Send copies, not originals. Ask for the decision in writing.

The plan has up to 72 hours to decide an urgent appeal, 30 days for care you have not had yet, and 60 days for care you already had. If it upholds the denial, ask about external review.