Medical Necessity Denial Success Stories

The Denial

Sarah M., 42, was diagnosed with HR+/HER2- metastatic breast cancer. Her oncologist prescribed Palbociclib (Ibrance) + Letrozole—a FDA-approved, guideline-recommended combination.

Insurer's reason: "Not medically necessary. Try letrozole alone first."

Reality: Sarah had already failed letrozole monotherapy. PET scans showed disease progression.

The Appeal Strategy

• Submitted oncologist's detailed letter of medical necessity citing failed prior treatments
• Referenced NCCN Category 1 guidelines (highest evidence level) recommending combination therapy
• Cited PALOMA-2 trial showing 10.3-month survival improvement vs. monotherapy
• Quoted policy language requiring coverage for guideline-based cancer treatments
• Included PET scan results showing progression on monotherapy

The Outcome

Insurer reversed denial after internal appeal. Sarah started treatment 2 weeks later. She's now cancer-free after 18 months of therapy.

The Denial

Michael T.'s 6-year-old son needed Applied Behavior Analysis (ABA) therapy for autism spectrum disorder. Insurer denied 40 hours/week as "not medically necessary."

Insurer's reason: "Excessive hours. Approve 10 hours/week maximum."

Reality: Child's developmental assessment showed severe delays requiring intensive intervention.

The Appeal Strategy

• Cited California state law (SB 946) mandating autism therapy coverage including ABA
• Submitted Board Certified Behavior Analyst's treatment plan with specific goals
• Provided research showing 40 hours/week is standard of care for severe autism
• Included functional behavior assessment documenting need for intensive therapy
• Referenced policy's compliance requirements with state mandates

The Outcome

Full 40 hours/week approved after appeal. After 12 months of ABA therapy, Michael's son showed 60% improvement in communication and 70% reduction in problematic behaviors.

The Denial

Jennifer L., 38, suffered chronic back pain from degenerative disc disease. Surgeon recommended minimally invasive lumbar fusion after failed conservative treatments.

Insurer's reason: "Experimental technique. Not medically necessary."

Reality: Procedure had FDA approval and extensive clinical use for 8+ years.

The Appeal Strategy

• Documented 18 months of failed conservative treatment (PT, injections, medications)
• Cited FDA 510(k) clearance for surgical device used in procedure
• Submitted 5 peer-reviewed studies showing safety and efficacy
• Included surgeon's letter detailing why open surgery posed higher risks for Jennifer's case
• Referenced Medicare coverage determination approving procedure
• Quoted policy definition of "experimental" and showed treatment didn't meet it

The Outcome

External review overturned denial. Independent medical examiner agreed procedure was evidence-based standard of care. Jennifer had surgery 3 weeks later and returned to work pain-free after 8-week recovery.

The Denial

David R., 29, needed intensive outpatient program (IOP) for treatment-resistant depression and suicidal ideation after psychiatric hospitalization.

Insurer's reason: "Not medically necessary. Weekly therapy sufficient."

Reality: Psychiatrist documented high suicide risk requiring daily monitoring and therapy.

The Appeal Strategy

• Cited Mental Health Parity Act requiring equal coverage to physical health conditions
• Submitted psychiatric evaluation showing suicide risk scores warranting IOP level of care
• Referenced American Psychiatric Association (APA) guidelines for depression treatment
• Documented failed outpatient therapy and medication trials over 2 years
• Noted policy covers "intensive medical treatment"—argued IOP qualifies under parity

The Outcome

Approved after David filed complaint with state insurance commissioner citing parity violation. Completed 6-week IOP program and has maintained stability for 18+ months on reduced medication.

The Denial

Amanda K., 35, tested positive for BRCA1 gene mutation (87% lifetime breast cancer risk). Sought prophylactic double mastectomy.

Insurer's reason: "Not medically necessary. Patient doesn't have cancer."

Reality: NCCN and major medical societies recommend prophylactic surgery for BRCA+ patients.

The Appeal Strategy

• Submitted genetic test results showing BRCA1 mutation
• Cited NCCN guidelines recommending risk-reducing mastectomy for BRCA+ carriers
• Included studies showing 90%+ breast cancer risk reduction from prophylactic surgery
• Referenced ACA requirement to cover BRCA counseling and testing
• Calculated long-term cost savings: prevention vs. future cancer treatment
• Submitted family history: mother died of breast cancer at 42, sister diagnosed at 38

The Outcome

Approved on first internal appeal. Amanda had surgery 6 weeks later. Five years later, remains cancer-free while her BRCA+ aunt was diagnosed—highlighting the value of prevention.