Free Appeal for “Not Medically Necessary” Denials
The insurer determined that the treatment, service, or procedure is not medically necessary for your condition. This is the most common denial reason and is often overturned on appeal.
62%
Appeal Success Rate
How to Appeal “Not Medically Necessary” Denials
When your insurer denies a claim as “not medically necessary,” it means the insurer determined that the treatment, service, or procedure is not medically necessary for your condition. this is the most common denial reason and is often overturned on appeal. Here are proven strategies to overturn this type of denial:
1.Obtain a detailed letter from your treating physician explaining medical necessity
2.Include peer-reviewed medical literature supporting the treatment
3.Reference clinical guidelines (AMA, NCCN, ACR) that support the service
4.Request peer-to-peer review between your doctor and the insurer medical director
5.Cite relevant state law requiring individualized medical necessity determinations
AMA / Clinical Guidelines
AMA CPT Guidelines state that medical necessity is determined by the treating physician based on clinical evidence and patient-specific factors.
Commonly Denied CPT Codes
992139921470553274472988143239
Winning Cases for “Not Medically Necessary”
Smith v. UnitedHealthcare (2024)
Smith v. UHC, No. 23-cv-4521 (S.D.N.Y. 2024)
Court ruled MRI was medically necessary when treating physician recommended it, overriding insurer utilization review.
Outcome: Won — $4,200
Johnson v. Anthem Blue Cross (2023)
Johnson v. Anthem, No. BC-2023-08812 (Cal. Super. 2023)
Insurer failed to have peer-to-peer review with treating physician before denial, violating Cal. Ins. Code § 790.03(h)(5).
Outcome: Won — $18,500
Martinez v. Kaiser Permanente (2024)
Martinez v. Kaiser, No. CGC-24-612345 (Cal. Super. 2024)
Independent Medical Review overturned denial of physical therapy sessions. DMHC found treating physician standard of care was appropriate.
Outcome: Won — $6,200
Thompson v. UnitedHealthcare (2023)
Thompson v. UHC, No. 22-cv-2891 (D. Minn. 2023)
Mental health parity violation. UHC applied stricter criteria to mental health treatment than comparable medical treatment.
Outcome: Won — $28,000
Relevant Statutes
Cal. Ins. Code § 790.03(h)(5)N.Y. Ins. Law § 4914
Other Denial Types
Pre-Authorization / Prior Authorization Required
58% success rate
Out-of-Network Provider
55% success rate
Experimental or Investigational
45% success rate
Coding or Billing Error
72% success rate
Service Not Covered Under Plan
40% success rate
Timely Filing Deadline Exceeded
35% success rate
Duplicate Claim
68% success rate
Policy Lapse / Not in Effect
55% success rate
Excluded Driver
48% success rate
Coverage Exclusion / Not Covered
35% success rate
Failure to Report Timely
42% success rate
Disputed Liability / At-Fault
50% success rate
Appeal Your “Not Medically Necessary” Denial
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