How to find the insurer's medical policy for your treatment

When a plan says your care is “not medically necessary”, it usually measured your case against a written clinical rule. Insurers call these medical policies, clinical criteria, guidelines or protocols. You are entitled to ask for that rule. Read your denial notice first, then ask in writing for anything it leaves out.

What this means

A medical policy is the plan’s own checklist for when it will pay for a treatment, test or drug. It is different from the plan document, which sets the contract terms. Your appeal is stronger when you can show, point by point, how your records meet the plan’s own checklist, or why the checklist does not fit your condition.

For job-based plans the federal claims rule says:

• If the plan relied on an internal rule, guideline or protocol, the denial notice must set it out, or say that it was relied on and that a copy is available free on request.
• If the denial rests on medical necessity, experimental treatment or a similar limit, the notice must explain the scientific or clinical judgment, applying the plan’s terms to your medical circumstances, or say that the explanation is free on request.
• For group health plans, the claim file includes any statement of plan policy or guidance about the denied treatment for your diagnosis, whether or not the plan relied on it.

Plans that are not grandfathered, and insurers, must also state the standard used to deny the claim and, on request, give the diagnosis and treatment codes and their meanings.

What to do

1. Reread the notice (your step). Look for a named guideline, a policy title or a code. Write down exactly what it says. If it names a rule but does not attach it, you still need a copy.
2. Ask in writing. Use the clinical criteria request letter. It asks for the rule, with its title, version and date, the clinical explanation, any plan policy on your diagnosis, and the plan provision the plan relies on. Say it is a request for documents and not an appeal.
3. Look where the plan may post it. Some plans publish their medical policies on their websites or member portals. If you find a policy, note its date and ask the plan to confirm it is the version used for your claim. The copy the plan sends you is the one that counts.
4. Send the request so you can prove it. Use certified mail with a return receipt, a fax with a confirmation page, or the portal with a screenshot. Write the date on your calendar.
5. Check the rule when it arrives. Is it the version in force when the plan decided? Does it cover your diagnosis? Does it list requirements you can match to your records? Does it allow exceptions?
6. Give it to your doctor (your doctor’s step). Ask your doctor to compare each requirement with your records. The result goes into the doctor’s letter. See what a strong letter of medical necessity contains.
7. Do not wait to appeal. You have at least 180 days after you receive the denial notice, and your plan may allow more. Check the date on your notice, which controls. If the rule has not come, file the appeal and say you asked for it, and when.

What the plan may say, and what to say back

“We applied our clinical guidelines.” Ask for the title, version and date of each guideline. The notice must set out the rule or say a copy is free on request.

“This information is for providers.” For mental health and substance use disorder benefits, the medical necessity criteria must be made available to any current or potential participant, beneficiary or contracting provider on request.

“The decision was a clinical judgment.” Ask for the clinical explanation applying the plan’s terms to your medical circumstances. If the notice did not include it, it is free on request.

The rule

If a plan relied on an internal rule, guideline or protocol to deny a claim, the notice must set it out or say a copy is available free on request, and a denial based on medical necessity or experimental treatment must explain the clinical judgment or say the explanation is available free on request. See sections 2560.503-1(g)(1)(v) and (j)(5) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.

Watch for

• Mental health and substance use care. Plans must make medical necessity criteria for these benefits available on request. For job-based plans under the Employee Retirement Income Security Act (ERISA), the documents due within 30 days of a request include the medical necessity criteria for both medical and mental health benefits, the processes and evidence the plan uses for limits such as prior authorization, and its parity comparison. See the parity comparison request letter.
• Medicare Advantage. The plan must follow Original Medicare’s coverage rules, including national and local coverage determinations. It may use its own criteria only when Medicare’s are not fully established, the criteria must rest on current evidence in widely used treatment guidelines or clinical literature, and the plan must post them publicly with a summary of the evidence and its reasoning. See Medicare Advantage.
• No set number of days. The claims rule says “free on request” but sets no response time for these items. Ask for a reply before your appeal is due.
• A policy is not the whole case. Meeting the plan’s checklist helps. If your doctor believes the checklist does not fit you, the letter should say why, with evidence. See how to find clinical guidelines and studies.

What next

• Using your plan’s own words: quote the plan’s definitions and exclusions.
• How to find clinical guidelines and studies: the outside evidence behind your doctor’s letter.
• What a strong letter of medical necessity contains: what to ask your doctor to write.