Medical Necessity Denials: Appeals

If you submit a claim that is denied as “not medically necessary, experimental, or investigational,” follow the outline below to help with your appeal. Medical necessity denials are especially vexing to a medical practice because they implicitly second guess a provider’s medical judgment, and appealing them can be burdensome because you have to “make the case” for coverage. However, it is important to appeal when you believe that the medical record supports the “medical necessity” of the procedure.

  • Review the definition of “Medical Necessity” in your provider contract.
  • Review the patient’s medical records, including surgical reports. Zero in on the specific aspects of the patient’s medical history and current condition that support the service or procedure.
  • Call the health plan to discuss the denial with the designated reviewer. Do not approach this call in an adversarial manner. Note that NCQA accredited plans are required to have a system for providers to discuss denials with clinical reviewers
  • Ask the designated reviewer for a copy (or a link) to any written payment policies relating to the procedure. These are critical; you will need them to make the case that the medical record supports the service.
  • Determine the process and timeline for appealing the claim. This should be outlined in the denial notification and your provider manual. There are typically several layers of internal appeals. Some plans now process appeals online.
  • Review scientific literature referenced in the payment policy.
  • If needed, perform a literature review to find articles that bolster your position.
  • Review ACFAS' Sample Written Medical Necessity Appeal for an example letter.

The appeal must include:

Key information from the claims denial (remittance advice) form: 

  • Claim Number
  • Patient’s Name
  • Policy Number/Group Number
  • Date(s) of Service
  • Provider’s NPI Number
  • Provider’s Contact Information

 Supporting clinical documentation:

  • Medical Record
  • Surgical Report
  • Labs/X-rays
  • Scientific Literature Supporting Your Position
  • Other Relevant Reports
  • A Narrative Succinctly Describing Why the Claims Denial was in Error.

Focus on the specifics of the patient at issue. Are there extenuating circumstances that would make a procedure that was not generally “medically necessary” for most people, necessary for this patient? Does providing the treatment avoid more expensive treatment in the future? The ACFAS' Sample Written Medical Necessity Appeal provides an example of this approach.

  • By Fax
    Make sure you save the confirmation of receipt.
  • By Ground Mail
    Consider sending “return receipt requested.” Many plans provide notice within a short period of receiving an appeal.
  • Online
    Save for confirmation.

Remember: Save a copy of the appeal!

Disclaimer: Information on this website does not constitute legal advice. ACFAS members should consult with their own lawyer for legal advice