anthemnot-medically-necessaryappeal-guide
Anthem Blue Cross Denial: Overturn "Not Medically Necessary"
March 1, 2026
9 min read
Anthem Blue Cross Blue Shield is notorious for denying claims as "not medically necessary." But this denial type has one of the highest overturn rates on appeal — over 50% when properly challenged.
Understanding Anthem's Medical Necessity Criteria
Anthem uses their own Clinical UM Guidelines to determine medical necessity. You have the right to request the specific guideline used in your denial.
Call Anthem at 1-800-331-1476 and ask for:
•The Clinical UM Guideline number and title
•The reviewer's name and credentials
•The specific clinical criteria you did not meet
Winning Case: Johnson v. Anthem Blue Cross (2023)
In Johnson v. Anthem (Cal. Super. 2023), the court ruled that Anthem failed to conduct a peer-to-peer review with the treating physician before denying a $18,500 surgical claim. The denial was overturned and Anthem was ordered to pay in full.
Appeal Strategy
1.Request the specific Clinical UM Guideline used
2.Have your doctor address each criterion point-by-point
3.Include peer-reviewed medical literature
4.Reference Johnson v. Anthem if in California
5.Demand a peer-to-peer review