Medical Necessity Denials: Checklist + Template Walkthrough
Why Medical Necessity Denials Are So Common
Few things are more frustrating than receiving a health insurance claim denial because your treatment was labeled “not medically necessary.”
You followed your doctor’s advice, submitted the paperwork, and expected coverage — but now you’re left confused and unsure of what to do next.
If this sounds familiar, you’re not alone. Medical necessity denials are among the most frequent insurance rejections, but here’s the good news: many of them can be successfully overturned with a well-documented, properly formatted appeal.
In this guide, you’ll find a checklist and walkthrough using our professional Medical Necessity Appeal Letter Template to help you confidently submit your appeal.
Step 1: Understand What “Medical Necessity” Really Means
Insurance companies define medical necessity as treatments or services that are:
Clinically appropriate
Proven effective by accepted medical standards
Not primarily for convenience or cosmetic reasons
A claim is typically denied for “lack of medical necessity” when:
The insurer believes a less costly or simpler treatment would suffice
The procedure is considered experimental or investigational
The doctor’s documentation doesn’t clearly justify the need
🩺 Pro Tip: Always review the denial letter closely. Identify the exact denial reason, the policy reference, and the appeal deadline listed.
Step 2: Gather All Supporting Documentation
A strong appeal depends on the strength of your evidence. Use this checklist:
✅ Denial letter (highlight the insurer’s reasoning)
✅ Doctor’s notes explaining why treatment was necessary
✅ Test results or medical imaging
✅ Peer-reviewed clinical research (if called “experimental”)
✅ Letter of medical necessity from your physician
💡 Internal Resource: Learn how to organize evidence in your appeal with our Appeal Guide.
Step 3: Follow the Insurance Appeal Instructions Exactly
Each insurer has its own appeal process. Missing a deadline can lead to automatic rejection.
Checklist for compliance:
Confirm the appeal deadline (usually 30–180 days).
Verify the correct mailing or upload address.
Submit via certified mail or online portal — keep proof.
Include all supporting documentation in one packet.
📄 Need help formatting? Use our Medical Necessity Denial Appeal Template — pre-formatted to meet insurer requirements.
Step 4: Write a Persuasive Appeal Letter (Using the Template)
Your appeal should be clear, factual, and respectful — never emotional or accusatory. Learn more in my FREE Appeal Guide.
Our Medical Necessity Appeal Template provides the perfect framework.
Section 1: Patient and Claim Information
Example: “Patient: Sarah Thompson | Policy #: 123456 | Claim #: 987654 | Date of Service: 08/12/2025”
Section 2: Statement of Appeal
“I am appealing the denial of my claim for a lumbar MRI, which was deemed not medically necessary. I respectfully request a reconsideration.”
Section 3: Medical Rationale
“My physician, Dr. Lopez, prescribed this MRI to assess potential nerve compression. Conservative therapy has failed to relieve symptoms.”
Section 4: Supporting Evidence
“Enclosed are clinical notes and published guidelines from the American Academy of Orthopaedic Surgeons confirming medical necessity.”
Section 5: Closing Statement
“Based on the enclosed evidence, I respectfully request that the denial be overturned. Thank you for your timely review.”
Step 5: Send and Track Your Appeal
After submitting your appeal:
Keep copies of your letter and attachments.
Follow up within 10–14 business days.
Mark response dates (insurers usually reply within 30–60 days).
If your appeal is denied again, you may still request an external review by an independent medical expert.
🧾 See my FREE APPEAL GUIDE for that next step.
Step 6: Avoid Common Mistakes
Common errors that weaken appeals:
❌ Missing the submission deadline
❌ Forgetting to include medical documentation
❌ Writing emotionally rather than factually
❌ Leaving out your signature or claim number
✅ Tip: Use our downloadable checklist in the Medical Necessity Template Bundle for a pre-filled format that keeps your documents organized.
Step 7: Real-Life Example of a Medical Necessity Denial
Scenario: Sarah’s claim for an MRI was denied because the insurer claimed “conservative therapy not fully exhausted.”
After submitting an appeal with her doctor’s detailed letter and therapy records, the denial was overturned within 21 days.
Denial Code: 50 — “Not Medically Necessary”
Outcome: Appeal approved after resubmission with complete medical documentation.
📘 Read more examples in our Denied Health Insurance Claims Explained article.
Conclusion: Turn Your Denial Into Approval
Insurance denials feel discouraging — but they’re often reversible with the right documentation and tone.
By following this checklist and using our Medical Necessity Denial Appeal Template, you can confidently build a strong case for coverage.
✅ Use Our Editable Attorney-Drafted Template
Download the Medical Necessity Denial Appeal Letter Template today to start your appeal with confidence.
Our pre-written legal appeal template helps you sound like an attorney without spending hundreds of dollars on hiring one!
