For many plans, a medical-necessity denial is appealable. The useful starting point is the written denial notice—not a phone summary—because the notice should identify the reason for the decision and the process for review.
For many employer plans subject to ERISA, Department of Labor guidance says a denial based on medical necessity must explain the scientific or clinical judgment or tell you how to obtain that explanation free of charge. That gives the prescriber something concrete to answer.
- Written denial notice
- Current medical-necessity policy or criteria
- Specific criterion the plan says was not met
- Records the reviewer used
- Missing or incorrect clinical information
- Prescriber response to each disputed criterion
- Internal appeal deadline
- External-review instructions if applicable
Get the exact criteria and decision record
Ask for the medical policy, utilization-review criteria, plan provision and records used for the decision. Compare the policy version and effective date with the date of the request.
If the insurer says a criterion was not met, write down the criterion word-for-word. Do not settle for “the doctor needs to send more information” without identifying what information is missing.
Match the chart to the rule
Confirm the insurer reviewed the correct diagnosis, severity, treatment history, prior therapies, laboratory or imaging information, dose, product and site of care. A denial based on an incomplete or mismatched record may need correction before a broad appeal.
Ask the prescriber to address the insurer’s actual criteria and explain why the requested treatment fits the patient’s documented situation. A generic letter that never mentions the denial reason is weaker than a point-by-point response.
Know when external review may matter
HealthCare.gov lists medical-judgment denials among the types that can qualify for external review under applicable protections. The final internal denial should tell you how the external-review process works for the plan.
Urgent cases can have faster pathways. Use the plan’s written instructions and document the clinical reason the case cannot safely wait for the standard timeline.
Use the source that actually controls your case
MedicineCostHelp can organize the problem, but the member-specific plan, payer decision, provider record or assistance program makes the actual determination. Keep written decisions, reference numbers and the documents that support the next step.