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.
Note the reviewer's specialty. A cardiologist denying a neurology request is an appeal argument in itself.
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. Standard requests must be decided within …
You have 65 days from the date on your denial notice to ask the plan to reconsider. A different reviewer than the one who denied you must de…
If your plan upholds its denial, it must automatically forward your case to an Independent Review Entity — you don't have to ask. The IRE is…
If waiting the standard timeline could seriously harm your health or your ability to function, you can demand an expedited appeal decided wi…
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 …