What does 'not medically necessary' actually mean?

It means the plan made a coverage determination that the requested care did not meet the applicable medical-necessity criteria. It does not replace medical advice from your treating clinician, and it can be challenged through the plan's appeal process.

What evidence can support a medical-necessity appeal?

A treating-clinician letter can address the plan's criteria point by point, supported by relevant records showing diagnosis, severity, prior treatment, objective findings, and applicable clinical guidelines. The right evidence depends on the stated denial reason.

"Not medically necessary": how to build a focused appeal

Q: What can I request from the plan?

Ask for the specific plan provision and clinical criteria, the scientific or clinical rationale applied to your circumstances, and the documents and records relevant to the decision. Federal disclosure rights and whether reviewer credentials must be provided depend on the plan type.

UPDATED JULY 2026 · U.S. PLANS · NOT LEGAL OR MEDICAL ADVICE

A medical-necessity denial is a coverage decision applying plan criteria to the information in the file. A focused appeal asks for those criteria, identifies any missing or disputed facts, and gives the reviewer case-specific clinical support. It does not guarantee reversal, but it creates a record tied to the actual denial reason.

What a focused appeal can address

If the plan lacked relevant records, the appeal can complete the file.
If a criterion was applied incorrectly, the appeal can connect the plan language to your facts.
A treating clinician can explain diagnosis, history, alternatives, and the clinical consequences of delay.

Step 1 — Demand their criteria

Call or write and request the specific plan provision and clinical policy, the scientific or clinical rationale applied to your circumstances, and the documents and records relevant to the decision. Many plans subject to federal claims rules must provide relevant records and the relied-on rule, guideline, or protocol without charge. You may also ask for the reviewing clinician's specialty or credentials; the disclosure requirement varies by plan type.

Step 2 — Get the doctor letter that answers those criteria

Ask your doctor for a letter of medical necessity that goes through the plan's criteria point by point: diagnosis with codes, severity, why this treatment, what was tried and failed, what happens without it, and relevant guidelines. Giving the clinician the actual denial and policy helps keep the letter tied to the disputed criteria.

Step 3 — Send the appeal

Free template — medical-necessity appeal

[Your name] · Member ID: [ID] Claim/Reference #: [number] · [Date] [Insurer] — Appeals Department [Address from denial letter] RE: Appeal — denial of [service/medication] as "not medically necessary," dated [date] To the Appeals Department: I appeal your denial of [service/medication] dated [date], which states the service is "not medically necessary." 1. TREATING PHYSICIAN'S DETERMINATION. My physician, Dr. [name] ([specialty]), examined me and determined this treatment is medically necessary for my diagnosis of [diagnosis, ICD code if known]. Their letter of medical necessity, enclosed, addresses your clinical criteria point by point. 2. CLINICAL HISTORY SUPPORTS NECESSITY. [1–3 sentences: symptoms/severity; treatments already tried and their outcomes; risk of delay or no treatment.] 3. REQUEST FOR THE RECORD. Please provide the specific clinical policy relied upon, the complete clinical rationale, and the specialty of the reviewing clinician. I request that any further review of this appeal be conducted by a physician of the same specialty as my treating provider. Enclosed: letter of medical necessity from Dr. [name]; medical records [list]; [guidelines/studies if any]; copy of the denial letter. I request that you reverse this denial. If it is upheld, please treat this letter as a standing request for the complete claim file, and be advised I intend to pursue independent external review. Sincerely, [Signature] · [Name] · [Phone]

If they uphold the denial

A final internal denial involving medical judgment may qualify for external review. An independent organization assigns a qualified reviewer with appropriate expertise under the applicable process. Follow the eligibility statement, destination, and deadline in the final denial; not every coverage dispute qualifies.

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Frequently asked questions

Who actually decided my care wasn't necessary?

A plan reviewer applied the plan's medical-necessity terms and clinical criteria. Ask for the rationale, relied-on policy, relevant records, and the reviewer's specialty or credentials. What the plan must disclose depends on the governing rules.

Is "not medically necessary" a final medical judgment?

No. It's a coverage decision, not a medical ruling. Your treating physician's documented judgment plus external review exist precisely to challenge it.

What are my odds?

There is no reliable universal success rate for an individual medical-necessity appeal. Outcomes depend on the plan terms, criteria, clinical record, and governing review process. A complete submission does not guarantee reversal.