It’s a gut punch. You or someone you love needs treatment, but your insurance suddenly says it’s “not medically necessary.” Now you’re stuck with a denial letter and bills you weren’t expecting. This happens to thousands every year, even when doctors recommend the care.
Knowing how to respond can make all the difference. Here’s what you should do if your insurance denies a service by calling it not medically necessary.
Understand Why Insurance Said "No"
Insurance companies decide what’s medically necessary based on their own guidelines. Sometimes they:
- Claim there isn’t enough evidence the treatment works
- See missing information in your doctor’s notes
- Think a cheaper or different treatment would work
- Flatly say they don’t cover the service
Look for these details in the denial letter. The insurance company should explain the reason for the denial and list your right to appeal. Circle or highlight key phrases—they might point out exactly what you need to prove in your appeal.
Photo by Vlad Deep
Don’t Panic—Document Everything
Breathe. Start by building your own record. Get a folder or digital file with:
- The denial letter and any emails or notes
- Your insurance policy (find the “medical necessity” section)
- Bills, treatment plans, and referral letters
- Notes from any calls you make (include names, dates, and what was discussed)
Keep every piece. Detailed documentation helps if you need a third-party review or end up at a hearing.
Talk to Your Doctor—They’re Your Best Ally
Doctors deal with insurance red tape all the time. Call your doctor or their billing staff. Ask if they:
- Can clarify, update, or expand your medical records
- Will write a detailed letter explaining why you need the service
- Know common arguments your insurance uses against claims like yours
Sometimes, a clearer explanation or extra records solve the problem before the appeal ever starts.
File an Internal Appeal—Act Fast
You have a right to appeal. Most insurance companies give you up to 180 days from the denial to file an internal appeal, but check the deadline in your denial letter to be sure.
Here’s how to make your appeal strong:
- Write a letter that explains why the service is necessary. Be specific. Reference your doctor’s notes and the insurance company guidelines.
- Include additional evidence. Attach test results, treatment plans, or studies that show the effectiveness of the treatment.
- Add a supporting letter from your doctor. Direct statements from medical professionals carry weight.
Send everything by certified mail if possible, or use your insurance portal so you have a record.
Request an Expedited Appeal for Urgent Needs
If waiting for the normal process would put your health at serious risk, you can often request an urgent (expedited) appeal. The insurer must respond quickly, often within three days. This is critical for treatments or medications that can’t wait.
Consider an Independent Medical Review
If your internal appeal is denied, you don’t have to stop fighting. Many states allow for an independent medical review (IMR) by a third-party medical expert who isn’t associated with your insurance company.
- Contact your state’s insurance department to start an IMR.
- The review checks your insurance’s medical necessity decision against accepted medical standards.
- If the reviewer sides with you, the insurer often must cover the service.
Get Help from a Patient Advocate
If you feel lost, reach out to a patient advocate or a legal aid group specializing in health insurance. They can help organize paperwork, explain your rights, and even draft appeal letters with you.
Websites like the Patient Advocate Foundation or Community Health Advocates offer free resources and sometimes direct support.
Contact Your State Insurance Department
If you don’t get anywhere with appeals, file a complaint with your state’s insurance regulator. This adds pressure and may spark a review. Some states even assign someone to help you push your case forward.
Stay Persistent—Appeals Often Work
Over half of denials for “not medically necessary” get overturned or changed through appeals or reviews. The process takes time, but persistence pays off. Insurers count on people giving up or missing deadlines.
What to Do If Appeals Fail
Sometimes, every appeal fails and the insurer won’t budge. At that point, you have a few last-resort options:
- File a civil lawsuit if you believe it was a bad faith denial.
- Work with your doctor on payment plans or financial assistance.
- Seek out programs or charities for rare or expensive treatments.
If the denied service is urgent, ask the provider if they’ll delay billing while you appeal. Some are willing to wait.
Tips for Success
- Meet deadlines: Missed deadlines mean lost rights.
- Communicate clearly: Use simple language and focus on facts.
- Stay organized: Keep every letter, form, and log.
- Ask for help: Don’t try to figure it out alone.
Conclusion
Insurance denials for “not medically necessary” are roadblocks, not dead ends. With the right steps—understanding your policy, working with your doctor, filing a thorough appeal, and leaning on outside review if needed—you can push back. Many people win or settle these fights, often with a little extra paperwork and patience.
Don’t let one letter stop you from getting the care you need. You have options, and fighting back is easier than you think.