claim denied not medically necessary Denial?
The insurance company is betting on your silence. They hope you see their "No" as final. We know better. Follow this tactical guide to force a reversal.
The Insurer's Playbook
Context: Health Insurance
Health insurance appeals are highly regulated. You have specific rights under federal and state laws (like ERISA or ACA). Speed is critical, but don't panic—internal appeals fix about 40-50% of errors.
Their Strategy
Attrition. They expect you to give up after the first denial letter. 40% of people do.
Your Counter-Move
Persistence. A formal, evidence-backed appeal shifts your claim from the "auto-reject" pile to "needs legal review."
Strategic Analysis
Breaking Down Your Denial
"Not Medically Necessary" is an Opinion, Not a Fact
This means the insurer's medical director (who has likely never met you) disagrees with your doctor's treatment plan. They think a cheaper option would have worked.
Your Appeal must include:
- A "Letter of Medical Necessity" from your actual doctor.
- Peer-reviewed studies supporting this treatment for your specific condition.
- Failure of "Step Therapy" (proof that you tried the cheaper option and it didn't work).
The Path to Victory
Execute these maneuvers precisely. Timing is everything.
"Request the insurer's 'clinical criteria' used to evaluate your claim."
"Ask your doctor for a detailed 'Letter of Medical Necessity' (LMN)."
"Include peer-reviewed studies or clinical guidelines supporting the treatment."
"Document any 'step therapy' failures (treatments you tried that didn't work)."
"Request a peer-to-peer review between your doctor and the insurer's medical director."
"If internal appeals fail, file for independent external review."
The Evidence Vault
Insurance companies use "insufficient documentation" as their #1 denial loophole. Don't give them the chance. Weaponize your appeal with these files:
Activate Your Professional Appeal
Our engine will synthesize everything into a formal legal challenge. No fluff. No begging. Just the facts they can't ignore.
Generate Your Appeal Letter
Free, personalized, and ready to send
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What type of insurance denied your claim?
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Intel Recap: Common Queries
The insurer's doctor says it's not necessary, but my doctor says it is. Who wins?↓
How do I prove a treatment is the 'Standard of Care'?↓
What if they suggested a different, cheaper treatment?↓
Integrity Officer
Sarah Jenkins, CIC
"People ask why I do this for free. It's because I spent 15 years on the other side. I know how the machine works. I know how they calculate settlements. And I know that when a policyholder fights back with the right data, the machine breaks and the policyholder wins."
Read my full story →