Medical Necessity Criteria and Appealing Denials


Insurance companies can deny your medical or mental health claims for a myriad of reasons. Because of this, the process of appealing those denials is usually an arduous and confusing one.


Here at Denials Management, Inc., our experienced medical insurance advocates help facilitate families going through this process. It is our job to make sure that your insurance claims are submitted correctly, and that once they are received by the insurance company, they are responded to fairly and accurately.


We see many reasons for claim denials, whether the insurance company states that there is a plan exclusion, timely filing issues, specific services are not a covered benefit, or that they find the services rendered to be “experimental.”


One of the most common denial reasons we see is called Medical Necessity.


So what is medical necessity and can you appeal medical necessity denials?


How to Determine Medical Necessity


There is not an all-encompassing list of medical necessity criteria,  nor one agency or governing body overseeing medical necessity denials. Often medical necessity is defined as, “Specifically referring to services, treatments, items, or related activities which are necessary and appropriate based on medical evidence and standards of medical care to diagnose and/or treat an illness or injury or; treatments, services, or activities that will enhance a patient’s health or that the absence of same will harm the patient.”


Different insurance providers and payers have differing medical necessity criteria, which can be confusing and can lead to a claim denial. However, medical necessity denials can be appealed and often have a good chance of being overturned.


Magnifying glass set on a health insurance policy booklet.


Appealing Medical Necessity Denials


If you have submitted a claim that is being denied due to medical necessity, it will often look like this. You receive a denial letter from your insurance company that reads similar to, “Upon clinical review, the patient doesn’t meet the plan’s criteria for medical necessity.” In most cases, this statement will be followed by another that states that the patient could have been treated at a lower level of care.


Essentially, what they are saying is that the treatment you or your loved one was, or is, receiving does not meet a certain level of severity to be considered medically important enough to warrant that treatment.


This is a very frustrating response to the families we serve, who send their child hundreds, sometimes thousands, of miles away from home for the appropriate—and often times life-saving and recommended—treatment, only to be told by a faceless individual that the care they have sought for their loved one does not in fact meet medical necessity criteria. It’s like being told, “you are overreacting.”


To make matters worse, in just about every single medical necessity denial case we have handled, the family has sought many other levels and types of care over an extended period of time before making the difficult decision to admit their child to the program in question.


Medical necessity denials can be discouraging, and in most cases, families end up paying out of pocket due to a lack of understanding. But here’s the truth: only about 20 percent of denials are ever appealed, meaning the insurance companies unjustly, and needlessly, benefit almost 80 percent of the time.


Medical Necessity Criteria


Medical necessity denials are broad and constitute the majority of the cases we see. We are extremely well-versed and adept at building strong arguments against this type of denial. Our Healthcare Advocates work hand in hand with families, creating a carefully developed plan which is essential to successfully appeal a claim denial.  


An advocate helping clients understand and appeal a claim denial because of medical necessity.


When you first begin working with our Healthcare Advocates they will need several documents from you. Probably one of the most important documents of all is a chronological history: a detailed timeline from the family’s perspective, highlighting all the incidents and behaviors that led to the patient’s treatment in question. We understand that these written histories can be difficult to create, but these chronologies really are the cornerstone to building the strongest possible case. It is important to provide these chronologies as promptly as possible, as they will help your advocate in their research to uncover insights and recognize what other documentation will be needed or helpful. As your Healthcare Advocate, we will always present you with examples of what we look for and need in a chronological history, and are capable of answering any questions you may have as to what information is pertinent and what is not.


External Level of Appeal Options


Medical necessity denials also open up the possibility of the External Level of Appeal, which is performed by an Independent Review Board (IRO). There is protocol, however, in order to reach this level of appeal.


  • One must fulfill all internal levels of appeals, which are reviewed by your insurance company. Normally, there are two levels of internal appeals, depending on the appeal rights outlined by your insurance company. This can vary, though, depending on the company.


Families then have two options once they’ve exhausted the internal level of appeals:


  1. IRO
  2. Litigation


The IRO (independent review board) is a team of reviewers comprised of medical professionals who have no affiliation with insurance companies, nor do they have any fiscal bias as to whether or not claims are paid or denied. Generally, this is where medical necessity denials appeals are given the full, fair, and objective review that families and patients deserve; and conversely, where we see the most denials overturned.


However, going the IRO route can be a double-edged sword: if the IRO review board upholds the denial, there will be yet another clinical denial letter attached to the case, which may alter a settlement should the family subsequently seek litigation. In some cases, choosing to move forward with an IRO will make it impossible to later litigate, as an IRO denial may dissuade an attorney from even taking your case. Your advocate is knowledgeable, knows the appeals process, and can advise you accordingly whether it is best to seek an IRO or go straight to litigation. Keeping an open line of communication with your Healthcare Advocate is the very first step in fighting against your wrongly denied claims.


If you have received a claim denial due to the absence of medical necessity and have any questions or need help, contact us. Our Healthcare Advocates are there for you and can help you determine the best path for appealing the claim.