What this denial means
A “not medically necessary” denial is the single most common reason US health insurers reject claims — roughly one in three denials. It sounds final, but it almost never is. It usually means the clinical documentation the insurer received did not, in their view, prove your care met the plan’s specific medical-necessity criteria. That is an evidence gap, not a verdict — and evidence gaps can be closed.
Why it’s worth appealing
Because the denial turns on documentation rather than your eligibility, it is one of the most winnable to appeal. Across US insurers, roughly half of properly filed appeals are overturned, yet under 1% of denials are ever appealed. A focused medical-necessity appeal backed by your physician frequently succeeds.
Submit a letter of medical necessity from your treating physician that cites the plan’s own clinical criteria and shows, point by point, how your case meets them.
What a strong appeal includes
A strong appeal references the exact denial language, attaches the records that demonstrate necessity, includes your physician’s letter of medical necessity, and formally requests a full internal review — and, if upheld, an independent external review. Appealify drafts this appeal letter for you, tailored to your denial.
How long you have
Most plans give you 180 days from the date on the denial notice to file an internal appeal. Some Medicare Advantage and other plans use shorter windows, so check your letter and act early. Missing the deadline is the most common reason a winnable appeal fails — so act early.
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