Medically necessary is the standard a plan applies when deciding whether to pay for something. It is the phrase at the centre of almost every denial letter, and it is worth reading carefully, because it does not mean what most people assume.
It is not a judgement that your care was unnecessary. It is a determination that the service, as documented, did not meet the plan’s written criteria for that service. Those are different claims, and only the second one is actually being made.
That distinction is what makes a denial appealable. The question on appeal is not whether you needed the care; it is whether the documentation matches the criteria. Which means the person who can move it is the one who writes the documentation, not you.
In New York: three things follow from that, and each is worth knowing before you write anything.
Ask for the criteria. A plan applying a medical necessity standard has written criteria behind it, and you can ask what they are and which one your case failed. That single request converts a vague denial into a specific one you can answer.
The prescriber’s letter is the appeal. Not your account of how you feel, useful as that is. The clinical record showing what was tried, what happened, and why the requested care fits the criteria is what decides it. Ask them to write to the criteria by name.
New York has an external appeal. After a plan’s internal appeal, a commercial or marketplace plan denial goes to an independent reviewer through the Department of Financial Services, someone who does not work for your insurer. On Medicaid, the route is the plan appeal and then a fair hearing, where the deadline for aid continuing is roughly 10 days rather than the 60 you have to request the hearing itself.
Two areas in New York limit where medical necessity review can operate at all. At an OASAS-certified facility in the plan’s network, an insurer may not require preauthorization for outpatient substance use disorder treatment, and may not run concurrent review during the first two weeks of continuous treatment, up to 14 visits. And it must give immediate access without prior authorization to substance use disorder medications on the state list. How parity works.
Also called: medical necessity, medically indicated. Full guide: How to appeal a denial in New York.
More in Glossary of health coverage and billing terms
- Out-of-pocket maximum — The out-of-pocket maximum caps your cost sharing for covered in-network care each plan year. What counts toward it, what never does, and the New York rules.
- Network (in-network and out-of-network) — The set of doctors and hospitals your plan has contracted with. Outside it, you pay much more.
- Formulary — A formulary is a plan's list of covered drugs, sorted into tiers that set your cost. What on-formulary means, how exceptions work, and New York's NYRx list.
This page explains how the system works. It is not medical advice. More.