Denied as “not medically necessary”
What it means
The insurer's reviewer decided your treatment doesn't meet their internal criteria for being needed — often without examining you, and sometimes without a specialist in your condition looking at the file.
Why insurers use it
It's the most flexible denial reason there is. “Medical necessity” is defined by the plan's own criteria documents, which are stricter than what most treating physicians consider standard care. It shifts the burden onto you to prove your own doctor right.
The counter-strategy
Demand the specific criteria used to deny — you're entitled to them.
Get a letter of medical necessity from your treating physician that speaks to each criterion point-by-point.
Cite peer-reviewed guidelines (specialty society standards) that support the treatment.
Ask whether the reviewer has expertise appropriate to the denied service. Do not assume a different specialty alone proves an improper review; the applicable program's reviewer standard controls.
In 31,504 published California external-review decisions on medical necessity denials, reviewers overturned the insurer 55.1% of the time. Source · See outcomes by treatment
Rights that apply to this denial
Your Medicare Advantage plan must give you a written decision when it denies a service or payment. A standard service decision is due within…
The filing rule is 60 calendar days after receipt of the denial notice. Receipt is presumed 5 calendar days after the notice date unless the…
If your plan upholds its denial in whole or in part, it must forward your case to an Independent Review Entity without a separate patient fi…
For services or items not yet furnished, you may request expedited reconsideration orally or in writing. The plan must expedite when it dete…
If the IRE also says no and the amount in dispute meets the yearly threshold, you can request a hearing before an Administrative Law Judge w…
If your health plan comes through a private employer, federal law gives you at least 180 days to appeal a denial. The plan must review your …