They said no and didn't really tell you why.
Your insurer calls this “Other reasons”. This page is about what that actually means and what you can do about it.
This is the single biggest category in the federal data, which tells you something: a denial you cannot understand is not a rare accident.
Is this your denial? Look for these words on your letter
“other”“see remarks”“denied per plan provisions”“not payable”
Not sure? Work out which denial you have →
The first thing to do. Make them say what they actually decided. You are entitled to the specific reason and the plan provision behind it — “other” is not a reason.
You are not a rare case
20,935,723
claims denied for this reason in the federal data — 33.8% of all categorised denials. This happens constantly, and it is beaten constantly.
Reason to keep going. Once they state a real reason, you have something to argue with. Getting them to say it out loud is the whole first move.
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. Their letter carries far more weight than yours alone.
- 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 "other reasons" denials
| Insurer | State | Claims |
|---|---|---|
| Health Options, Inc. | Florida | 2,246,035 |
| Blue Cross and Blue Shield of Alabama | Alabama | 1,699,001 |
| Blue Cross and Blue Shield of Florida | Florida | 1,504,889 |
| Blue Cross and Blue Shield of South Carolina | South Carolina | 1,269,906 |
| Blue Cross and Blue Shield of NC | North Carolina | 1,088,291 |
| Blue Cross Blue Shield of Illinois | Illinois | 920,178 |
| AvMed, Inc. | Florida | 745,924 |
| Blue Cross Blue Shield of Oklahoma | Oklahoma | 594,951 |
| UnitedHealthcare of Texas, Inc. | Texas | 564,886 |
| SelectHealth, Inc. | Utah | 533,852 |
| HMO Louisiana, Inc. | Louisiana | 470,275 |
| Ambetter of Peach State Inc. | Georgia | 466,806 |
Everything you need for a "other reasons" 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.