Not medically necessary

When a plan writes “not medically necessary”, it means it does not agree that you need this service, test, drug or setting. It is not a statement that the service is excluded, and it is not a finding about you. It is a medical opinion by the plan’s reviewer, and you can answer it with medical evidence.

What this means

The plan’s decision rests on a rule or guideline: the plan’s own medical policy, or a published criteria set it licenses. Your task is to show that you meet that rule, or that the rule should not decide your case. Three kinds of argument work, and a strong appeal uses all three:

• Your situation. What happens to you without the service, in your words and your doctor’s: symptoms, function, risk.
• Clinical evidence. Your records, test results, the treatments already tried, and published guidelines or studies that support the service for your diagnosis.
• Policy and process. The plan’s own wording, and any step the plan skipped.

What the plan must give you. A denial notice must state the specific reason and the plan provisions relied on. If the plan relied on an internal rule, guideline or protocol, the notice must set it out or say a copy is free on request. If the denial rests on medical necessity, it must either explain the clinical judgment, applying the plan’s terms to your medical circumstances, or say that the explanation is free on request. On appeal, the reviewer must consult a health care professional with appropriate training and experience in the field, who was not consulted on the first decision. You can also ask for the names of the medical experts whose advice the plan obtained.

External review. Denials involving medical judgment, including medical necessity, appropriateness, health care setting, level of care and effectiveness, qualify for the federal external review process. If your plan is insured, your state’s process applies where it meets the federal standards. Denials based on a finding that you do not meet the plan’s eligibility requirements do not qualify.

Medicare Advantage. A plan must follow Original Medicare’s coverage rules and may use its own criteria only when Medicare’s are not fully established. The criteria must be based on current evidence in widely used treatment guidelines or clinical literature, and the plan must post them publicly. Medical necessity decisions must take into account your history, your physician’s recommendations and clinical notes.

Medicaid for people under 21. The state must cover any service that federal law allows and that is medically necessary to correct or ameliorate a condition found by screening, whether or not the state’s Medicaid plan normally covers it. The state decides case by case.

What to do

1. Get the reason and the criteria. Use the clinical criteria request and the claim file request. Ask for the reviewer’s specialty. (You.)
2. Read the plan’s medical policy. Compare each requirement in it with your records. Mark the ones the plan says you did not meet. (You and your doctor.)
3. Ask your doctor for a peer-to-peer call. The doctor speaks directly to the plan’s reviewer. Ask the office whether the plan limits how long after the denial a call can be requested. (Your doctor.)
4. Ask your doctor for a letter. It should state your diagnosis, history, treatments tried, test results, what will happen without the service, and why alternatives are not suitable. It should answer each point in the plan’s criteria. The clinician letter on medical necessity is the model. (Your doctor.)
5. Add evidence. Attach the relevant guideline or study and highlight the lines that fit your diagnosis. State regulators such as the Washington insurance commissioner publish past independent review decisions, which show the reasoning reviewers used for similar cases. (You and your doctor.)
6. Write the appeal. Use the medical necessity appeal letter. Answer the stated reason. Attach the packet. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial to appeal. Check the date on your notice, which controls. (You.)
7. Ask for urgency where it applies. If delay could seriously harm your health, your doctor can say so, and an urgent decision is due within 72 hours. (Your doctor.)
8. Request external review after the final denial. You have at least four months. (You.)

What the plan may say, and what to say back

“The service does not meet our medical necessity criteria.” Ask which criteria and for a copy. Answer each point with a record or a sentence from your doctor’s letter.

“A less costly alternative is available.” Have your doctor explain what was tried, what happened and why the alternative would not work for you.

“There is no evidence it works for your condition.” Send guidelines and studies, and see the guide on experimental or investigational denials.

The rule

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 available free on request. 29 Code of Federal Regulations (CFR) 2560.503-1

Watch for

• A vague letter. A one-line note that the service is “medically necessary” is weak. Specifics win.
• Wrong setting. Plans also deny the setting (for example inpatient versus observation). The hospital stay denials guide covers that.
• Late appeals. Do not wait for the full time limit. Care often cannot wait.
• Plans without appeal rights. Short-term plans, health care sharing ministries and fixed indemnity plans fall outside the Affordable Care Act appeal rules.

What next

• Peer-to-peer review: how your doctor talks to the plan’s reviewer.
• A strong medical necessity letter: what the doctor’s letter should contain.
• How external review works: the independent review.
• Experimental or investigational: when the plan says the evidence is not enough.