What does 'not medically necessary' mean on my insurance denial?
It's the plan's most common appealable denial — and it doesn't mean the service isn't needed. Here's what it actually means and how to fight it.
When your plan says a service isn't 'medically necessary', they're saying the service doesn't meet their internal coverage criteria for your specific clinical situation. NOT that the service isn't actually necessary. Plans use criteria from InterQual or MCG, supplemented by their own medical policy. These criteria are reviewable, citable, and frequently inconsistent with current specialty-society guidelines.
Steps
- Get the plan's specific medical-necessity criteria they applied (they MUST provide this on request)
- Get the relevant specialty-society guideline that supports the service for your indication (NCCN for oncology, ADA for diabetes, AHA/ACC for cardio, etc.)
- File a formal internal appeal citing both
- After internal exhaustion, request external review by an Independent Review Organization (the IRO decision binds the plan)
- DenialHelp drafts the appeal letter in 5 minutes
Frequently asked questions
What does 'not medically necessary' mean on my insurance denial?
When your plan says a service isn't 'medically necessary', they're saying the service doesn't meet their internal coverage criteria for your specific clinical situation. NOT that the service isn't actually necessary. Plans use criteria from InterQual or MCG, supplemented by their own medical policy. These criteria are reviewable, citable, and frequently inconsistent with current specialty-society guidelines.
What are the steps?
1. Get the plan's specific medical-necessity criteria they applied (they MUST provide this on request); 2. Get the relevant specialty-society guideline that supports the service for your indication (NCCN for oncology, ADA for diabetes, AHA/ACC for cardio, etc.); 3. File a formal internal appeal citing both; 4. After internal exhaustion, request external review by an Independent Review Organization (the IRO decision binds the plan); 5. DenialHelp drafts the appeal letter in 5 minutes
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