My health insurance says it's not medically necessary — now what?

Use the free tool — Health Plan Denial Appeal

What "not medically necessary" actually means

This is one of the most common denial reasons on a health plan explanation of benefits. It usually means a reviewer at the plan — sometimes a nurse, sometimes a doctor who has never examined you — decided your treatment did not meet the plan's clinical criteria. It is a judgment call, not a paperwork error, and that matters because it changes how you appeal.

About half of appealed denials get overturned. Almost nobody appeals. The letter hides the real reason in codes and hides the deadline in fine print.

Your appeal rights and deadlines

You generally have 180 days to file an internal appeal with the plan.
If the plan upholds the denial, you generally have 4 months to request an external review by an independent reviewer.
Both deadlines are computed from the date on your denial letter — not the date you read it.
These rights come from the ACA (45 CFR 147.136), ERISA claims rules (29 CFR 2560.503-1), and Florida Statutes 627.6472 / 627.602, for employer and ACA marketplace plans.
This does not cover Medicare, Medicare Advantage, or Medicaid fee-for-service — those have their own appeal systems. If your denial is from Medicare, use Medicare Decoder instead.

Confirm the exact dates in your own letter and with your plan. This is general information, not legal advice, and it cannot see your plan document.

What to request from the plan

The clinical criteria or guideline the reviewer used to deny the claim.
The reviewer's credentials — whether they were qualified to judge this specific treatment.
Any documents the plan is required to give you free of charge to support your appeal.

Building the appeal letter

An effective appeal addresses what the plan is actually required to consider: the clinical criteria it used, your doctor's medical rationale, and the prior-authorization facts of your case. A letter built around these points — with medical-necessity points your doctor can sign — gives the appeal real substance instead of just disagreement.

If you need free help

Florida Division of Consumer Services: 1-877-693-5236
For employer plans, U.S. DOL EBSA: 1-866-444-3272

This tool is not legal or medical advice and does not file appeals for you. It explains ACA, ERISA and Florida appeal rules for employer and marketplace plans only. Always confirm deadlines and requirements with your plan or a professional.

What to do next

Paste the denial letter or explanation of benefits into the free tool. It reads the date, reason code, service, and plan type directly from your own document, and gives you the plain-language reason, the two appeal deadlines already computed, the records to request, and a draft appeal letter — built from your own numbers and dates, not examples.

Use the free tool

Health Plan Denial Appeal is an informational tool for commercial (employer, ACA marketplace, individual) health plan denials, based on the ACA (45 CFR 147.136), ERISA claims rules (29 CFR 2560.503-1) and Florida Statutes 627.6472 / 627.602 as of 2025–26. It does not cover Medicare, Medicare Advantage or Medicaid fee-for-service, which have their own appeal systems. It is not legal or medical advice and does not file appeals. It is not affiliated with any insurer, employer or agency.