Health insurance denial: “not medically necessary”

This notice

The denial says, “This service is not medically necessary.” That is the plan’s coverage decision under its criteria, not medical advice about whether you need care.

Urgent?

Many covered plans allow 180 days after the denial notice for an internal appeal, but use the deadline printed on your letter. Request expedited review if waiting could seriously endanger life, health, or the ability to regain function.

First move

Ask the insurer for the exact clinical rule, guideline, or protocol used for the denial.

Official path

1. Keep the denial, Explanation of Benefits, plan document, claim number, and every related medical record.
2. Request the clinical criteria and a free copy of documents the plan relied on.
3. Ask the treating clinician for a letter that connects your diagnosis, history, prior treatment, and requested care to those criteria.
4. File the internal appeal using the address, form, deadline, and authorization instructions in the denial.
5. Request expedited review if the medical situation meets the urgent standard described by the plan.
6. Use the denial’s external-review instructions if the internal appeal is denied, and find state help through the CMS Consumer Assistance Program.

What people reported

Often helps

• Patients reported stronger appeals when the clinician answered the insurer’s stated criteria instead of sending only a general note.
• Patients reported that a short timeline of symptoms, prior treatments, failures, and risks made large medical files easier to review.

Often fails

• Patients reported resending the same records without the denial criteria or a focused clinical explanation and receiving the same result.

Template

[YOUR FULL NAME]
[YOUR ADDRESS]
[CITY, STATE ZIP]
[DATE]

[HEALTH PLAN APPEALS DEPARTMENT]
[ADDRESS OR PORTAL ON THE DENIAL]

Re: Internal appeal, member ID [MEMBER ID], claim [CLAIM NUMBER]

To the appeals reviewer:

I appeal the denial dated [DENIAL DATE] for [SERVICE OR TREATMENT], which states that the service is not medically necessary. I request a full and fair review under my plan’s appeal process.

My treating clinician, [CLINICIAN NAME], recommends this care because [SHORT CLINICAL REASON]. My relevant history includes [DIAGNOSIS, PRIOR TREATMENTS, AND RESULTS]. The enclosed clinician letter and records explain how the request meets the plan’s clinical criteria and why the proposed alternative is not appropriate for my situation.

Please review all enclosed information, provide the exact guideline or protocol used, and reverse the denial if the plan terms and evidence support coverage. If you uphold the denial, please send the complete written reason and instructions for external review.

[IF URGENT: I request expedited review because waiting may seriously jeopardize [LIFE / HEALTH / ABILITY TO REGAIN FUNCTION].]

Sincerely,
[YOUR FULL NAME]

Enclosures: [LIST ENCLOSURES]

Stop here if…

• Waiting for a standard appeal could endanger life, health, or the ability to regain function; seek care and request expedited review immediately.
• The denial concerns an ongoing hospital stay, emergency service, or discharge; ask the plan and care team for the urgent review process now.
• The plan misses its deadline or the case involves a self-funded employer plan you cannot navigate; contact the applicable regulator, benefits office, or lawyer.

FAQ

What does “not medically necessary” mean?

It means the plan says the requested care does not meet its coverage or clinical criteria. It is a coverage decision, not a medical instruction to stop care.

Can my doctor file the appeal?

A clinician can supply records and a support letter, and may act as your authorized representative if plan rules are followed. Keep your own complete copy.

Can I request external review before the internal appeal ends?

Usually external review follows the final internal denial. In urgent situations, you may be able to request expedited internal and external review at the same time.

Where can I get help in my state?

CMS lists state Consumer Assistance Programs and, where none operates, other contacts such as the state Department of Insurance. Your denial should also name the applicable appeal route.