What was denied
Treatments, tests and equipment
Care called not medically necessary or experimental: surgery, imaging, hospital stays, equipment and therapy.
Do this today
- Use the tool: Denial reason finder Match the wording on your letter to a denial reason, see who must act first, and open the right playbook.
- Read: Equipment, home health and therapy limits 5 minute read. What to do when a plan denies medical equipment, home health care or therapy visits, or says you used up a visit limit. Also what Medicare says about care that maintains your condition.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- Equipment, home health and therapy denials are usually argued as medical necessity: what you need, why, and what happens without it.
- A visit limit may not be final. If more visits depend on medical necessity, the denial can be appealed and can go to external review.
- In Medicare, skilled care to maintain your condition or slow decline can be covered even if you are not expected to improve.
Read the full guide: Equipment, home health and therapy limits
More guides, tools and letters
More guides, tools, letters 21
Guides
- Equipment, home health and therapy limits
What to do when a plan denies medical equipment, home health care or therapy visits, or says you used up a visit limit. Also what Medicare says about care that maintains your condition.
- Experimental or investigational
Your plan says a treatment is experimental, investigational or unproven. Learn how to use the plan's own definition and how to bring evidence and your doctor's judgment.
- Hospital stay denials
A plan may deny a hospital admission, cut a stay short, or call you an outpatient under observation. Here is what to do, including Medicare's fast appeal for discharges and the childbirth stay rule.
- Not medically necessary
What "not medically necessary" means on a denial. See what the plan must show you, how to build an appeal with your doctor, and when independent external review applies.
Tools
- Tool
Denial reason finder
Match the wording on your letter to a denial reason, see who must act first, and open the right playbook.
Letters and scripts
- Letter or script
Appeal: equipment or supplies
Asks your plan to cover medical equipment or supplies it denied, using your plan's own wording, your prescriber's order and how the equipment is used in your daily life.
- Letter or script
Appeal: experimental or investigational
Asks your plan to reverse an experimental or investigational denial, to explain its clinical reasoning for your diagnosis, and to answer the evidence your doctor relies on.
- Letter or script
Appeal: level of care
Asks your plan to approve the level or setting of care your clinician recommended, such as a hospital stay or residential program, instead of a lower one.
- Letter or script
Appeal: not a covered benefit
Asks your plan to name the exact provision it relied on and to cover care that falls within a benefit your plan document describes.
- Letter or script
Appeal: not medically necessary
Asks your plan to reverse a medical necessity denial, using the plan's own standard and your records, and to have a clinician in the right field review it.
- Letter or script
Off-label or experimental use letter (for your clinician)
A letter in your clinician's voice that responds to an experimental, investigational or off-label denial with the clinical reasons and the evidence for this patient. Every clinical statement is a blank for the clinician to complete.
Denial reasons
- Denial reason
Care is ending
Hospital, rehab, nursing home or home health care ending? Medicare: call the reviewer on your notice by noon the day after you get it, or 1-800-MEDICARE (1-800-633-4227). Medicaid or job-based plan: see What to send.
- Denial reason
Cosmetic
Your plan says the surgery or treatment is meant to change how you look, not to treat a medical problem. The fight is usually over whether it treats a real medical or functional problem, and over the plan's own definition of cosmetic.
- Denial reason
Custodial care
Your plan says the nursing, home health or facility care you get is help with daily living, not skilled medical care. If skilled staff are doing the work, you can challenge the label, and Medicare does not require that you are improving.
- Denial reason
Experimental or investigational
The plan says the treatment is unproven or still being tested. That is a medical question, so the appeal rests on evidence. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.
- Denial reason
Level of care
Your plan agrees you need treatment but says a less intensive setting would do. For example, outpatient care instead of residential care, or a lower-intensity program instead of a hospital stay.
- Denial reason
Not a covered benefit
The plan says your policy does not cover this service. Read the exact exclusion, check whether the service really falls inside it, and check whether a law requires the plan to cover it anyway.
- Denial reason
Not medically necessary
The plan says the care is not needed under its own definition. That is a medical judgment, so your doctor's letter carries the appeal. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.
- Denial reason
Observation instead of inpatient
The hospital kept you but billed the stay as outpatient observation. If you were formally admitted and then switched, you can appeal in two cases, and must ask before you leave to keep billing protection. If never admitted, this right does not apply.
- Denial reason
Visit or benefit limit reached
Your plan says you used up the visits, days or dollars it covers for a service this year. Check the count, check whether the plan allows more when it is medically necessary, and check whether mental health care is limited more than other care.
- Denial reason
Wrong site of service
Your plan will pay for the service but not where your doctor wants it done, such as a hospital outpatient department instead of a doctor's office. Whether the setting is safe for you is a medical judgment you can challenge.
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.