They say you didn't need the treatment. Your doctor says you did.

You are not a rare case, and this is the measured version of that: 3,968,921 claims were denied for this reason in the federal file. It is not unusual, it is not a judgment about you, and it is beaten constantly.

• Ranked by volume this is the seventh most common of the 9 denial reasons in the federal file, 4.6% of every categorized denial.
• 98 of the 185 insurer-state records in the file recorded at least one denial under this reason, so it is not one company's habit.
• The single largest block of them sits with Celtic Insurance Company in Texas: 382,578 claims, 9.6% of every denial recorded under this reason nationally.
• It leans hardest in North Dakota, where it is 19.5% of all categorized denials, and lightest in Nebraska at 0%.
• Across the 98 records that report it the middle one recorded 2,665 claims under this reason, against 382,578 at the top of the range and 11 at the bottom, the same reason, two orders of magnitude apart between insurers.
• Insurers in every one of the 30 states in this release recorded it, so nothing about it is local.
• The largest single state block sits in Texas: 1,082,079 claims, 27.3% of every denial recorded under this reason nationally.
• The largest reason in the file, other reasons, was recorded 7.08 times as often as this one , 28,113,631 claims against 3,968,921.
• 87 insurer-state records reported none under this reason at all, and the 98 that did averaged 40,499 claims each.

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.

What to do about this denial

1. 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.
2. Answer the reason given, not the diagnosis. An appeal that argues the wrong point fails even when the claim is good.
3. 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.
4. Internal appeal first, then external review. Internal generally within 180 days of the denial; external generally within 4 months of the final internal denial.

Insurers recording the most "not medically necessary" denials

Where a “not medically necessary” denial is common, and where it is not

Every state whose insurers recorded this reason at all, with how much of that state's categorized denials it accounts for and where it ranks among the reasons recorded there. Computed from the plan-year 2026 release of the CMS file, not quoted from anyone's summary.

A high share here describes what the insurers in that state wrote on their denial notices, not whether those denials were right. The spread runs from Texas at 1,082,079 claims down to Nebraska at 186.

How big this reason is next to the other 8

The same file, the same year, every other categorized denial reason expressed as a multiple of the 3,968,921 claims denied as “not medically necessary”.

Your evidence checklist, free, and the whole list

This is what decides a "not medically necessary" appeal. Four of these eleven items are things your plan must hand you free of charge on request under the federal claims procedure regulation. Ask for them before you argue: an appeal written without them is argued against criteria nobody in the room has read. Work down it in order.

The letter that gets you items 2 to 5, published in full, free

This is the document-request letter, complete and unredacted. It uses four federal rights to make your plan hand over its entire case before you write a word of your appeal. Send this first, whatever your denial reason. The Kit fills it in from your details and pairs it with the letters for the appeal itself, but the letter below works exactly as it stands.

[Your name]
[Your address]

[Today's date]

[Insurer name]
Appeals Department
[Address from your denial letter]

RE: Request for claim file and plan documents
    Member name: [Your name]
    Member ID: [Member ID]
    Claim / reference number: [Claim number]
    Date of service: [Date of service]
    Date of denial notice: [Date of denial]

To whom it may concern,

I am appealing the denial of the claim above. Before I submit my full appeal, I am
requesting the documents I am entitled to receive, so that my appeal can address the
actual basis of your decision.

Under 29 CFR 2560.503-1(h)(2)(iii), I am entitled, upon request and free of charge, to
reasonable access to and copies of all documents, records and other information relevant
to my claim. Paragraph (m)(8) defines what is relevant. On that basis I request:

1. The complete claim file, including everything relied upon in making this determination,
   and everything submitted, considered or generated in the course of making it, whether or
   not it was relied upon. (m)(8)(i) and (m)(8)(ii)

2. Any statement of policy or guidance held by the plan concerning the denied treatment or
   benefit for my diagnosis, whether or not it was relied upon in this decision. This
   includes the medical policy, clinical criteria, coverage guideline or technology
   assessment applied to my claim, and the date it was last reviewed. (m)(8)(iv)

3. The identification of any medical or vocational experts whose advice was obtained on
   behalf of the plan in connection with this determination, whether or not that advice was
   relied upon, including their specialty and board certification. (h)(3)(iv)

4. The documents demonstrating compliance with the administrative processes and safeguards
   required in making this determination. (m)(8)(iii)

5. The specific plan provision on which the denial relies, and the section of the plan
   document or Evidence of Coverage in which it appears.

6. A complete copy of the plan document or Evidence of Coverage in force on the date of
   service.

Please send these to the address above. I am also giving notice that I intend to appeal,
and I ask that this request not be treated as my appeal or as a substitute for it. I will
submit my full appeal within the applicable deadline.

If you consider that any part of this request falls outside what the regulation requires,
please say so in writing and identify which part and on what basis, rather than declining
the request as a whole.

Sincerely,


[Your name]
[Telephone]

Questions about a "not medically necessary" denial

Everything you need for a "not medically necessary" denial: your two deadlines, the argument that fits your denial reason, the letters, the clinician brief, and the external review request. One payment. No subscription. No cut of your claim. Opens on screen the moment you pay. 14-day refund, no questions, one email to hello@getaxionlabs.com.