Appeal a Medical Necessity Denial

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The health plan makes its denial decisions based on policies identified in the policy booklet you receive. This policy booklet lists those procedures and services that the health plan will cover or exclude for payment, as well as, identifying items that must be pre-authorized before payment is made. If a medical service or procedure is denied, then the health plan should forward to you and the physician a denial in writing, explaining the details of why the procedure or service was denied.

A common form of denial is due to lack of medical necessity. This may occur if the physician prescribes a treatment that is considered to be experimental, investigational, cosmetic, an off-label use of a medication or is listed as a non-covered benefit by the health plan.

How do you combat a medical necessity denial? The following are steps you should take in appealing your medical necessity denial.

1. Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

2. Verify with your physician’s office that the office staff sent a letter of medical necessity and all accompanying medical records (pathology reports, operative reports) required by the health plan to justify if the procedure is medically necessary. (If the office had not done so, then request that the medical office send a letter reconsidering the denial and attach all the necessary medical documentation).

3. Most health plans will consider medical procedures to be cosmetic (such as injection treatments for varicose veins), unless there is an indication of pain. Did your physician include pain or discomfort in your medical records?

4. Experimental and/or investigational procedures may be covered if the physician writes a letter of medical necessity and provides two articles from established medical journals specifying the benefits and successes of the proposed treatments. (A medical group in Los Angeles appealed the denial of an off-label use of a medication for AIDS patients and won 50% of its appeals using this method)

Journal of the American Medical Association
The New England Journal of Medicine

5. A health plan may consider paying for an item not usually covered by the policy in order to avoid a more expensive option. For example, a case manager of a health plan received an invoice for a mattress by a patient in home health care. The patient wanted a more comfortable mattress if he was going to spend long time periods in bed recuperating from his car accident. A mattress is not a medical item, and is therefore, not a covered benefit and not considered medically necessary. However, paying for the mattress and keeping the patient satisfied at home was less expensive than having the patient in the hospital. The case manager approved the payment for the mattress, but at a negotiated rate.

Medical necessity denials could be overturned if you provide the required information, request assistance from your physician and confirm your options within your policy booklet.