Your treatment was denied as "not medically necessary." Now what?
Proving medical necessity requires more than just your doctor saying you need treatment. You need clinical evidence, policy references, and documentation that demonstrates treatment is essential, appropriate, and evidence-based.
This guide shows you exactly what evidence to gather and how to present it persuasively.
What "Proving Medical Necessity" Actually Means
To overturn a denial, you must demonstrate your treatment meets ALL of these criteria:
- Clinically appropriate for your diagnosis
- Evidence-based according to medical research
- Essential to treat or manage your condition
- Not experimental or investigational
- No equally effective cheaper alternative
Let's break down how to prove each element.
Step 1: Obtain a Detailed Letter of Medical Necessity
Your doctor's letter is the cornerstone of your appeal. It must go beyond "Patient needs this treatment." Here's what to request:
Pro tip: Many doctors write generic letters. Provide your doctor with bullet points of what insurers need to see. Make it easy for them to help you.
Step 2: Gather Clinical Evidence
Back up your doctor's letter with independent research:
Peer-Reviewed Studies
Search PubMed, Google Scholar, or medical databases for studies showing treatment effectiveness for your condition. Include:
- Study titles and publication dates
- Key findings (success rates, patient outcomes)
- Relevance to your specific diagnosis
Clinical Practice Guidelines
Professional medical societies publish treatment guidelines. Find recommendations from:
- American Medical Association (AMA)
- National Institutes of Health (NIH)
- Specialty societies (e.g., American Cancer Society for oncology)
- National Comprehensive Cancer Network (NCCN) for cancer treatments
FDA Approval Status
For medications and devices, note:
- FDA approval date and indications
- Clinical trial results that led to approval
- Any "off-label" uses supported by research
Step 3: Document Your Medical History
Show why treatment is necessary for you specifically, not just your condition in general:
Insurers often deny by saying "Try X first." Your history proves you already did.
Step 4: Reference Your Insurance Policy
Insurers must follow their own rules. Find and quote policy language that supports coverage:
- Coverage sections: Locate where your treatment type is listed as covered
- Medical necessity definition: Show how treatment meets THEIR criteria
- Exclusions: Confirm your treatment isn't explicitly excluded
- Prior authorization: If you followed requirements, note compliance
Where to find your policy: Request "Summary Plan Description" and full policy documents from your HR department or insurer.
Step 5: Address Alternative Treatment Objections
Insurers frequently deny by claiming cheaper alternatives exist. Counter this by:
- Documenting failed alternatives: "Patient tried generic medication X for 6 months with no improvement"
- Explaining contraindications: "Patient is allergic to first-line treatment Y"
- Citing effectiveness differences: "Studies show brand-name drug is 40% more effective for this subtype"
- Showing long-term cost savings: "This surgery prevents future hospitalizations costing $200K+"
How to Organize Your Evidence
Present your appeal in a clear, professional structure:
Section 1: Executive Summary
One paragraph stating: your diagnosis, denied treatment, why it's medically necessary, and what you're requesting.
Section 2: Medical Background
Your diagnosis, symptom progression, treatments tried, and current status.
Section 3: Clinical Justification
Doctor's letter of medical necessity with supporting research citations.
Section 4: Policy Compliance
Quote policy language requiring coverage and show how you meet criteria.
Section 5: Conclusion & Request
Restate why denial should be overturned and specifically request approval.
Appendices
Attach all supporting documents (medical records, research studies, policy excerpts).
Skip the Research—Generate Your Appeal in 5 Minutes
AppealArmor's AI finds relevant research, quotes your policy, and formats everything professionally.
Start Free Appeal →Evidence Requirements by Treatment Type
For Medications
- FDA approval status and indications
- Clinical trial results showing efficacy
- Failed trials of generic/formulary alternatives
- Documented side effects from cheaper options
For Surgeries & Procedures
- Clinical guidelines recommending procedure
- Failed conservative treatments (PT, medication, etc.)
- Imaging showing severity (MRI, X-ray, CT results)
- Surgeon's statement of medical necessity
For Therapy & Rehabilitation
- Treatment plan with specific goals and duration
- Progress notes showing improvement
- Research on evidence-based therapy methods
- Functional assessments demonstrating need
For Diagnostics (MRI, Genetic Testing, etc.)
- Why diagnosis cannot be made with cheaper tests
- How results will change treatment plan
- Clinical guidelines recommending diagnostic
- Urgency or safety factors requiring imaging
What If You Don't Have All This Evidence?
Start with what you have and build from there:
- Week 1: Request letter of medical necessity from doctor
- Week 2: Search for 3-5 peer-reviewed studies supporting treatment
- Week 3: Obtain medical records and policy documents
- Week 4: Draft and submit appeal with available evidence
Don't wait for "perfect" evidence. Submit a strong appeal with what you can gather in 30 days, then supplement during the review process if needed.
Red Flags That Weaken Your Case
Avoid these mistakes that give insurers ammunition to deny again:
- Vague doctor letters: "Patient needs treatment" without specifics
- Missing alternatives: Not addressing why cheaper options won't work
- No research citations: Claims without evidence
- Emotional arguments: "I'm suffering" without clinical data
- Incomplete medical history: Gaps in timeline or treatments tried
- Ignoring policy language: Not demonstrating compliance with criteria
Let AI Build Your Evidence-Based Appeal
83% success rate. Free appeal letter generator with policy analysis and research citations.
Generate Appeal Now →The Bottom Line
Proving medical necessity isn't about begging—it's about meeting insurers' own criteria with documented evidence. When you demonstrate treatment is clinically appropriate, evidence-based, and essential for YOUR specific case, insurers have no valid reason to deny.
Most importantly: you don't need to be a medical researcher. Work with your doctor, gather supporting studies, and present organized evidence. That's all it takes to win 80%+ of appeals.