What does 'not medically necessary' actually mean?

It means the plan agrees the treatment exists and is covered in principle, but decided that in your specific case it was not clinically warranted under the plan's internal criteria. That decision is appealable, and the criteria the plan used are disclosable on request.

How often do medical necessity appeals win?

Across 73,987 real external-review outcomes we analyzed, 46.9% of appealed denials were overturned overall, and medical-necessity denials specifically about 47% of the time (n=56,180). A denial is a first answer, not the final word.

Do I have to write the letter myself?

No. Apellica reads your denial, builds the medical-necessity appeal around your records and the plan's own criteria, and a senior reviewer checks it before it goes out. $0 upfront, and you pay only if we win.

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Medical necessity

How to Write a Medical Necessity Appeal Letter That Wins

A "not medically necessary" denial is one of the most appealable decisions a carrier makes. Here is the structure that overturns it, the federal rule that controls, and the evidence that wins.

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The four parts that overturn a medical necessity denial

1. Quote the denial and the criteria used

Name the carrier's exact wording back to them, and demand the specific clinical guideline or criterion they applied. Under 29 CFR 2560.503-1(g)(1)(v), an employer (ERISA) plan must disclose the rule or protocol it relied on. Once you have it, you can rebut it point by point.

2. Map your record to each criterion

A medical necessity denial says your records did not meet the plan's bar. Answer it with the chart notes, prior treatments tried and failed, diagnostics, and functional measures that satisfy each element the plan named. Generic pleas to reconsider do not move a reviewer; a point-by-point match does.

3. Add the treating-physician letter

A letter of medical necessity from your provider, tied to the plan's own criteria and the clinical record, carries weight. It should state why this treatment, for this patient, is medically necessary now, and why alternatives are unsuitable or have failed.

4. Cite the rule and state the relief and deadline

Cite the standard that governs your plan (29 CFR 2560.503-1 for employer plans, 45 CFR 147.136 for ACA plans), which guarantees a full and fair review. State exactly what you want and note your appeal is timely. You generally have at least 180 days from the date on the denial.

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Apellica builds the medical-necessity appeal around your records and the plan's own criteria, with the controlling regulation cited and every fact checked by a senior reviewer. Medical-necessity denials are overturned about 47% of the time (n=56,180).

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Frequently asked questions

What does 'not medically necessary' actually mean?: It means the plan agrees the treatment exists and is covered in principle, but decided that in your specific case it was not clinically warranted under the plan's internal criteria. That decision is appealable, and the criteria the plan used are disclosable on request.
How often do medical necessity appeals win?: Across 73,987 real external-review outcomes we analyzed, 46.9% of appealed denials were overturned overall, and medical-necessity denials specifically about 47% of the time (n=56,180). A denial is a first answer, not the final word.
Do I have to write the letter myself?: No. Apellica reads your denial, builds the medical-necessity appeal around your records and the plan's own criteria, and a senior reviewer checks it before it goes out. $0 upfront, and you pay only if we win.