Medical Necessity Denial — How to Appeal

What to Do When Insurance Says Treatment Was “Not Medically Necessary”

A medical necessity denial does not mean your treatment was unnecessary. It means the insurance company claims the treatment did not meet their criteria — which are often applied narrowly or incorrectly.

These denials are among the most commonly reversed when appealed correctly.

This page explains:

• What a medical necessity denial really means

• Why insurers issue these denials

• How appeals fail — even when treatment was appropriate

• What to do next to appeal effectively

What Is a Medical Necessity Denial?

Medical necessity denials typically include language such as:

• “Not medically necessary”

• “Does not meet clinical criteria”

• “Treatment not supported by guidelines”

• “Level of care not justified”

In plain terms, the insurer is saying:

You received treatment, but we don’t agree it was required under our standards.

This is not a medical decision by your doctor — it’s an insurance determination.

Why Insurers Deny Claims as “Not Medically Necessary”

These denials often occur when:

• The insurer applies internal criteria more strictly than medical practice

• Medical records were submitted without proper framing

• Key details supporting necessity were not highlighted

• The insurer relies on generalized guidelines instead of your specific condition

The issue is usually not the lack of medical evidence, but how that evidence is presented.

Why Medical Necessity Appeals Commonly Fail

Many otherwise valid appeals fail because:

• The appeal focuses on fairness rather than criteria

• Medical records are submitted without explanation

• The appeal does not directly address the denial rationale

• Arguments are presented out of sequence

• Emotional language replaces clinical framing

Insurers are trained to review appeals for criteria alignment, not persuasion.

What a Successful Medical Necessity Appeal Must Do

A strong medical necessity appeal must:

• Address the insurer’s stated reason for denial directly

• Frame medical evidence around plan or guideline standards

• Emphasize why the treatment was required for this patient

• Present information in the order insurers expect to see it

Simply restating that treatment was “necessary” is not enough.

The Most Effective Way to Appeal a Medical Necessity Denial

Because these appeals depend heavily on structure and framing, using the correct appeal format matters.

An attorney-written medical necessity appeal template is designed to:

• Follow insurer review logic

• Frame medical records properly

• Avoid language insurers routinely disregard

• Preserve appeal rights and deadlines

👉 Medical Necessity Appeal Letter Template

This template is designed for patients who want to act quickly — without guessing how to structure the appeal.

Still Unsure If This Is Your Denial Type?

Some denials mention medical necessity alongside other reasons.

If your denial letter is confusing:

• Start with Which Appeal Letter Do I Need?

• Or use Free AI Prompts to clarify the denial language

Don’t Wait Too Long

Medical necessity appeals often have strict deadlines, sometimes as short as 30–60 days.

Waiting to “research more” is one of the most common reasons valid appeals fail.

Insurance Appeal Deadlines — What to Know

Bottom Line

Medical necessity denials are not personal — they are procedural. They are often reversible when appealed with the right structure, right framing, and right timing.

Use the Medical Necessity Appeal Letter Template and submit a compliant appeal before your deadline expires.

Medical Necessity Denial — FAQs

Q: What does “not medically necessary” mean in an insurance denial?
A: It means the insurance company claims the treatment did not meet its criteria for coverage, even if a doctor ordered it. It is not a medical judgment about whether the treatment helped.

Q: Are medical necessity denials appealable?
A: Yes. Medical necessity denials are among the most frequently appealed and overturned when the appeal addresses the insurer’s criteria directly.

Q: Does prior authorization prevent a medical necessity denial?
A: No. Insurers can still deny claims as not medically necessary even after approving prior authorization, which is a common source of disputes.

Q: How long do I have to appeal a medical necessity denial?
A: Appeal deadlines vary by plan, but many are 30, 60, or 180 days from the denial notice.