They say you didn't need the treatment. Your doctor says you did.
Your insurer calls this “Not medically necessary”. This page is about what that actually means and what you can do about it.
Someone who has never examined you read a summary of your file, checked it against a written policy, and decided it didn't qualify. Your doctor examined you and decided it did.
Is this your denial? Look for these words on your letter
“not medically necessary”“does not meet medical necessity criteria”“not medically appropriate”“criteria not met”
Not sure? Work out which denial you have →
The first thing to do. Get the policy they judged you against. You cannot argue with a checklist you have not seen — and they have to give it to you free.
You are not a rare case
2,819,765
claims denied for this reason in the federal data — 4.6% of all categorised denials. This happens constantly, and it is beaten constantly.
Reason to keep going. This is the denial most often overturned, because an independent reviewer judges it on clinical evidence rather than the insurer's own policy.
What to do about this denial
- Get the exact wording. Ask for the specific plan provision and clinical criteria relied on. The plan must supply it free of charge on request.
- Answer the reason given, not the diagnosis. An appeal that argues the wrong point fails even when the claim is good.
- Get your treating clinician to write the counter. For this denial type especially: a letter of medical necessity citing your records and current clinical guidance is the single most effective document you can add.
- Internal appeal first, then external review. Internal generally within 180 days of the denial; external generally within 4 months of the final internal denial.
Why external review matters here: this denial type turns on medical judgement, which is exactly what external review exists for. Your case is judged by an independent organization that does not work for your insurer, and the insurer is required by law to accept the decision. Nationally, 44% of external reviews went in the patient's favour — yet only 1 in 24,654 denials ever gets there.
Insurers recording the most "not medically necessary" denials
| Insurer | State | Claims |
|---|---|---|
| Ambetter of Peach State Inc. | Georgia | 336,480 |
| Cigna Health and Life Insurance Company | Tennessee | 259,198 |
| Blue Cross and Blue Shield of South Carolina | South Carolina | 207,047 |
| Celtic Insurance Company | Florida | 202,591 |
| Ambetter of Magnolia Inc. | Mississippi | 135,304 |
| Molina Healthcare of Ohio, Inc. | Ohio | 135,301 |
| Celtic Insurance Company | Texas | 134,292 |
| Celtic Insurance Company | Missouri | 126,559 |
| Superior Health Plan | Texas | 125,674 |
| Cigna Health and Life Insurance Company | Florida | 123,618 |
| Celtic Insurance Company | Arkansas | 93,258 |
| Celtic Insurance Company | Tennessee | 64,962 |
Everything you need for a "not medically necessary" denial: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
This page presents federal statistics and a general description of appeal rights created by federal law. It is not legal, medical, or insurance advice, and no outcome is guaranteed. Your denial letter and plan documents govern your specific case. Free help is available from your state's Consumer Assistance Program and from the federal Marketplace at HealthCare.gov.