Denied as “Not Medically Necessary”? How to Appeal

Written by Aptiva Health Editorial Team · Reviewed by Taylor Sorrels, Esq. and Crystal Brake, RCM Director · Editorial & review standards · How we research

“Not medically necessary” is one of the most common reasons a health plan says no. The words can sound like the plan is saying you don’t really need care. That is not usually what it means.

It usually means this: the plan’s reviewer did not see enough proof, in the records they had, that you meet the plan’s rules for this service. Fix the proof, and you have a real chance to win.

This guide explains what the denial means, what evidence turns it around, and how to appeal. It is part of the Coverage & Appeals Center.

What the letter says vs. what it means

Each plan has written rules for each service. They go by different names: medical policy, coverage policy, clinical criteria, or guideline. The reviewer compares your records to those rules. If something is missing, the answer is often “not medically necessary.”

The evidence that overturns it

You win this kind of appeal by answering the plan’s own rules, one at a time.

1. Get the plan’s policy

Ask the plan for a free copy of the exact medical policy it used (29 CFR 2560.503-1(g)(1)(v)). Read the criteria. They are often a checklist. For example, a policy may require a certain number of weeks of other treatment, certain test results, or certain symptoms.

2. Match your records to each criterion

Go down the checklist. For each item, find the record that proves it:

• Visit notes that describe your symptoms and how long you have had them.
• Records of treatments you already tried, such as physical therapy, medicine or injections, and how they worked.
• Test and imaging results.
• Notes on how the problem affects daily life, like work, sleep or walking.

If a criterion isn’t met, ask your clinician whether there is a medical reason the rule doesn’t fit you. That reason belongs in the letter.

3. Get a letter of medical necessity

Your clinician’s letter is the most important part. A strong letter:

• Names your diagnosis and the care requested.
• Quotes or lists the plan’s criteria and shows how you meet each one.
• Explains why this care is needed now.
• Lists what was already tried, for how long, and the result.
• Explains the risk of waiting or of a different option.
• Cites a professional guideline when one supports the care.

It helps to give your clinician’s office a copy of the plan’s policy and your denial letter.

4. Ask about a peer-to-peer review

Sometimes your clinician can talk directly with the plan’s reviewing doctor. This is called a peer-to-peer review. Ask your clinician’s office if one is possible.

How to appeal a “not medically necessary” denial

1. Mark your deadline. Find the appeal deadline on the denial letter and put it on your calendar.
2. Request the plan’s policy. Ask for the criteria the plan used and a copy of your claim file (29 CFR 2560.503-1(h)(2)(iii)).
3. Share it with your clinician. Send the denial letter and the policy to your clinician’s office and ask for a letter of medical necessity.
4. Collect records that match each criterion. Gather notes, test results and treatment history.
5. Write a short appeal letter. Use the template below and attach everything.
6. Send it and keep proof. Use the method on the denial letter. Save the fax confirmation, mail receipt or portal screenshot.
7. Ask for external review if needed. If the plan upholds the denial, request an external review before that deadline.

Sample appeal letter

[Your name]
[Your address] · [Your phone] · [Your email]

[Date]

[Plan name] — Appeals Department
[Address or fax from your denial letter]

RE: Appeal of "not medically necessary" denial
Member name: [Name]
Member ID: [Number]
Claim / reference number: [Number]
Service: [Service requested]
Ordering clinician: [Name, credentials]
Date of denial letter: [Date]

To the Appeals Department:

I am appealing your decision that [service] is "not medically necessary." I believe I meet the criteria in your policy, [policy name or number].

Your policy requires:
1. [Criterion 1] — Met. See [record, date], page [#].
2. [Criterion 2] — Met. See [record, date], page [#].
3. [Criterion 3] — Met. See [record, date], page [#].

[If a criterion does not fit: "My clinician explains why [criterion] does not apply to me in the enclosed letter."]

Enclosed:
- Letter of medical necessity from [clinician]
- Medical records from [dates]
- Your policy with the criteria I meet marked
- Your denial letter

Please reverse the denial. If you do not, please tell me in writing the specific reason, the criteria used, the name and credentials of the reviewer, and how to request an external review.

[If urgent:] My clinician believes waiting could seriously harm my health. I request an expedited review.

Sincerely,
[Signature]
[Printed name]

Free sample letters from the Washington Office of the Insurance Commissioner and the Patient Advocate Foundation are listed under Sources.

Deadlines

Deadlines depend on your plan type and state. Use the earliest date that applies, and confirm it with your plan.

Self-funded employer plans use the federal external review process, not the state’s. See Kentucky and Indiana for the state steps.

When to escalate

Ask for an external review if the plan upholds the denial after your internal appeal. In Kentucky and Indiana, “not medically necessary” denials are the kind of decision state external review is designed for (KRS 304.17A-600; IC 27-8-29-12).

You can also contact your state Department of Insurance with questions or a complaint:

• Kentucky Department of Insurance: (800) 595-6053, Option 1 (in Kentucky), or (502) 564-6034 (KY DOI Division of Consumer Protection)
• Indiana Department of Insurance Consumer Services: (800) 622-4461 (IDOI Consumer Services)

If you have a self-funded employer plan, the state may not regulate it. Ask the plan for its federal external review steps.

Related denial types

• If the problem was approval in advance, see denied for missing prior authorization.
• For procedure-specific help, see how to get an MRI, physical therapy or an epidural steroid injection covered.

Examples by type of care

The same denial looks a little different for each kind of care. These are common patterns, not rules for your plan.

• Imaging, such as an MRI. Plans often want to see how long you have had symptoms, your exam findings, and treatment tried first. See getting an MRI covered.
• Physical therapy. Plans often look for measurable goals and progress, and may limit visits. See getting physical therapy covered.
• Spine injections. Plans often want a diagnosis that fits, imaging that matches, and proof an earlier injection helped. See getting an epidural steroid injection covered.

Common mistakes to avoid

• Arguing in general. “I really need this” is not enough. Show, criterion by criterion, how you meet the plan’s policy.
• Leaving out what you already tried. If the plan wants proof of earlier treatment, list every therapy, medicine and visit, with dates.
• A short or vague clinician letter. Ask your clinician to address the exact words in the denial.
• Waiting too long. File before the deadline, even if a record is still on the way.