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Insurance denied: not medically necessary. How to appeal
Your health insurance denied a claim as not medically necessary. What it means, your deadline, and how to appeal.
Check my letter freeWhat it means
The insurer says the service was not needed for your condition, based on its clinical criteria.
What to do
Ask your doctor for a letter of medical necessity: your condition, the treatments already tried, and why this service is needed now.
Ask the plan for the clinical criteria it used, and answer each point.
In 2023, 44% of appealed in-network denials in HealthCare.gov plans were overturned (KFF).
Your deadline
Most plans give you 180 days from the denial notice to file an internal appeal. Original Medicare gives 120 days from the Medicare Summary Notice, and Medicare Advantage plans 65 days from their decision. Check the date printed on your letter.
If the plan says no again
After a final denial from a marketplace or employer plan, you can ask for an external review by an independent reviewer within 4 months. If the reviewer decides for you, the plan must pay.
Ask for your claim file
You have the right to receive, free of charge, copies of the documents and the criteria used to decide your claim.
Other denial reasons
- No prior authorization
- Out of network
- Experimental or investigational
- Billing or coding error
- Not covered by your plan
- Claim filed too late
- Other insurance (coordination of benefits)
- Coverage not active