Your claim was denied as not medically necessary. Here is what to do.

What is a not medically necessary denial?

A not medically necessary denial is a coverage opinion from your insurer, usually made by a reviewer who never examined you, and you can appeal it.

Medically necessary generally means care needed to diagnose, treat, or prevent a health condition, judged against accepted medical standards. It sounds like a medical fact. It is not. It is a decision made from a file, and it is the most common denial and one of the most beatable.

Can I appeal if my doctor ordered the treatment?

Yes. When a plan says care your doctor ordered was not necessary, the person who treated you is the one with standing to say what you needed.

Your treating provider's written word, such as a note, a chart entry, or an after-visit summary saying the care was needed, directly contradicts a paper reviewer. A documented link to a diagnosis in the chart also gives a far clearer necessity argument than care with no diagnosis written down.

What are the steps to appeal a not medically necessary denial?

You appeal in four steps, and you do not have to win the medical argument yourself. You have to put your provider's judgment in front of someone with the authority to overturn the decision.

• Step 1: Get the written denial. Download it from your insurer's member portal, or call member services and ask for the written denial and the reason code for your claim. Find the reason, the claim details, your appeal rights, and the deadline.
• Step 2: Collect your side. Ask your provider for a written note saying the care was needed, and pull your chart notes and itemized bill. You have a federal HIPAA Right of Access to your own records, and the provider must respond within 30 days.
• Step 3: File an internal appeal before the deadline. Send the insurer your provider's note and a clear statement of why the denial is wrong. A short letter filed before the deadline on your denial protects your rights, and you can add detail later.
• Step 4: Ask for external review if they uphold it. An independent reviewer who does not work for the insurer decides, and the decision is binding on the plan. If waiting would seriously risk your health, request an expedited appeal, decided in days.

Do I need a lawyer to appeal a denial?

No, you can start on your own with the steps above. CheckMyDenial prepares your side and helps you understand it. We are not your lawyers, and this is not legal advice.