Appealing Medical Necessity Denials

If you have submitted a medical claim that is being denied due to medical necessity, it will often look like this. You receive a medical denial letter from your healthcare 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 medical statement will be followed by another that states that the patient could have been treated at a lower level of care.

Basically, what they are saying is that the medical 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 medical treatment.

This is a very frustrating reply to the families we care, who send their child hundreds, sometimes thousands, of miles away from home for the appropriate—and often times life-saving and recommended—medical 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 medical denials are ever appealed, meaning the healthcare insurance companies unjustly, and needlessly, benefit almost 80 percent of the time.

If you have submitted a medical claim that is being denied due to medical necessity, it will often look like this. You receive a medical denial letter from your healthcare 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 medical statement will be followed by another that states that the patient could have been treated at a lower level of care.

Basically, what they are saying is that the medical 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 medical treatment.

This is a very frustrating reply to the families we care, who send their child hundreds, sometimes thousands, of miles away from home for the appropriate—and often times life-saving and recommended—medical 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 medical denials are ever appealed, meaning the healthcare insurance companies unjustly, and needlessly, benefit almost 80 percent of the time.

Isabella Bautista is a dedicated healthcare professional. Ms. Isabella Bautista' command over various medical topics gives her an edge as a content writer and sets her apart from the rest.