Your Insurance Denied Your Treatment. What Should You Do First?

Seeing the word DENIED on a letter from your health insurance company can make your stomach drop.

Maybe your doctor ordered a procedure you have been waiting for. Maybe it is a medication you finally found after trying other options. Maybe you have already spent months going to appointments, completing tests, or trying treatments that did not work.

Now the insurance company is saying no.

It is understandable to want to immediately call the insurance company, contact your doctor's office, or start writing an appeal.

But before you do any of those things, there is something more important to figure out:

What exactly was denied, and why?

Not every denial requires the same response. Understanding what happened first can save you time and help you decide what to do next.

First, Make Sure You Actually Have a Denial

This may sound obvious, but insurance paperwork can be confusing.

An Explanation of Benefits, commonly called an EOB, may show that a claim was denied or that an amount was not paid. That does not necessarily mean you have received a formal denial of a request for treatment.

Your provider may also tell you that an authorization is still pending, that additional information has been requested, or that the insurance company needs something else before making a decision.

Before assuming you need to appeal, determine exactly where things stand.

Ask:

Was the treatment formally denied?

Is the prior authorization still being reviewed?

Did the insurance company request additional information?

Was a claim denied after the service was already provided?

Did I receive an official denial notice explaining my appeal rights?

These are very different situations, and the right next step depends on what actually happened.

Read the Denial Letter Before You Start Fighting the Decision

When a denial letter arrives, it is tempting to skim until you find the word denied and immediately start making phone calls.

Take a few minutes and read the entire letter.

Look for information explaining:

• What service, medication, procedure, or treatment was denied

• Why the request was denied

• What information was reviewed

• Whether a medical necessity review was performed

• What clinical criteria or medical policy was used

• How to request an appeal

• Where an appeal must be submitted

• The deadline for filing

• Whether an expedited appeal may be available in certain circumstances

• How to obtain additional information about the decision

Keep the denial letter.

Save a copy somewhere you can easily find it. Do not assume it will always remain available in your insurance portal.

Find the Actual Reason for the Denial

“Denied” tells you the outcome.

It does not tell you what needs to be fixed or challenged.

A treatment may be denied because the insurance company determined that medical necessity requirements were not met. But there are many other reasons a request or claim may be denied.

For example, the insurer may say:

• Required medical records were not received

• A required treatment has not been tried

• The requested service is considered experimental or investigational under the plan

• Prior authorization was required but was not obtained

• The requested provider is out of network

• The service is excluded from the health plan

• The documentation submitted did not support the requested level of care

• The member was not eligible for coverage on the date of service

The next step depends heavily on the reason.

An appeal focused on medical necessity will not resolve an eligibility problem.

Sending more clinical records may not change a benefit exclusion.

And writing a lengthy appeal may not be necessary if the authorization is still open and simply waiting for information that can be submitted.

Before deciding how to respond, understand the problem you are actually trying to solve.

Was Your Treatment Denied After a Medical Necessity Review?

If your denial mentions a medical necessity review, it generally means the health plan evaluated clinical information related to the requested treatment or service to determine whether it met the applicable medical necessity requirements.

This is an important distinction.

A denial following a medical necessity review is different from a denial caused by an eligibility issue, a benefit exclusion, or another administrative problem.

During a medical necessity review, the health plan may compare the information submitted by your healthcare provider with specific clinical criteria or a medical policy.

Depending on the health plan and the service being requested, those requirements may come from the insurer's own medical policies, licensed clinical criteria, government coverage requirements, or other clinical guidelines.

If the insurer determines that the information submitted does not demonstrate that the applicable requirements have been met, the request may be denied.

That does not always mean the treatment did not happen, the symptoms are not real, or your doctor does not believe the treatment is appropriate.

Sometimes the issue is what the documentation submitted to the insurer actually shows.

Ask What Criteria Were Used During the Medical Necessity Review

If your treatment was denied following a medical necessity review, one of the most important things to identify is the standard used to make the decision.

Start with the denial letter.

It may name the medical policy, clinical criteria, or guideline that was applied.

If it does not, contact the insurance company and ask:

“What criteria or medical policy were used during the medical necessity review, and which requirement was not met?”

You can also ask how to obtain a copy of the applicable policy or criteria.

Knowing what standard was used can help you and your healthcare provider better understand why the request was denied.

For example, the criteria may require documentation of a particular symptom, diagnostic finding, previous treatment, length of treatment, or response to therapy.

You may discover that you actually meet the requirement.

The next question becomes whether the medical documentation submitted to the insurer clearly demonstrates it.

Want to understand more about where insurance medical necessity criteria come from? Read: “Who Decides What's ‘Medically Necessary’? Inside the Criteria Health Insurance Companies Use.”

Compare the Denial With Your Actual Medical History

Suppose the insurer says there is no documentation showing that you completed physical therapy before a requested procedure.

But you did.

Now there are more questions to answer.

When did you attend physical therapy?

Where did you receive it?

How long did you participate?

Why did therapy end?

Did your specialist document that history?

Does the physical therapy provider have additional records?

Were those records included with the original authorization request?

The information may already exist somewhere in your medical record. The challenge is identifying where it is and determining whether the insurance company received it.

This is one reason keeping your medical and insurance information organized before a denial occurs can be helpful.

Look for the Gap Between What Happened and What Was Submitted

This is an important part of reviewing a medical necessity denial.

There can be a difference between what happened during your care and what the insurance reviewer had available when making the decision.

Imagine that you tried a medication months ago and had to stop because of side effects.

You remember it.

Your doctor remembers it.

But the clinical note submitted with the authorization only says “previous medication failed” without explaining which medication was tried, when it was taken, or why it was stopped.

If the insurer's criteria require more specific documentation, the reviewer may determine that the requirement was not demonstrated by the information submitted.

That is why simply saying, “But I already tried that,” may not be enough.

The question becomes:

Where is it documented?

Understanding that difference can help you determine what information may need to be gathered before an appeal.

Talk With Your Healthcare Provider

Your doctor's office should know about the denial, especially if the request involved a treatment they ordered.

Ask whether the office received a copy of the denial and whether they know why the request was denied.

You may also want to ask:

• What records were submitted with the original request?

• Did the insurer request additional information?

• Was anything requested that has not yet been sent?

• Is additional documentation available?

• Is a peer to peer review available?

• Does the provider believe an appeal is appropriate?

• Are there clinical records that specifically address the reason for denial?

Your provider may have information you do not have.

You may also remember previous treatments or healthcare services that are not obvious from the records initially submitted.

Both can help identify where additional documentation may exist.

Do Not Miss the Appeal Deadline

If you have received a formal denial, find the appeal deadline immediately.

Do not rely on memory.

Write it down and keep the denial letter somewhere you can easily find it.

Appeal rights and deadlines vary depending on the health plan, type of coverage, type of denial, and circumstances. Review the instructions in your denial notice and applicable plan documents carefully.

If anything about the deadline or appeal process is unclear, contact the health plan and ask for clarification.

Document the date of the call, the representative's name, any reference number provided, and what you were told.

Start Building a Timeline

You do not have to wait until you are writing an appeal to start organizing what happened.

Create a simple timeline.

When was the treatment recommended?

When was the prior authorization submitted?

Was additional information requested?

When was it sent?

When did you call the insurance company?

What were you told?

When was the medical necessity review completed?

When was the denial issued?

What treatments have you already tried?

When did important tests or imaging occur?

Which providers have relevant medical records?

A timeline can help you identify missing pieces before you begin preparing an appeal.

It can also make conversations with your provider and insurance company easier.

Keep Track of Every Insurance Conversation

If you begin calling the insurance company about the denial, document those conversations.

Record the date and time of the call, the representative's name, the phone number you called, any reference number provided, what you asked, what you were told, and what is supposed to happen next.

Also write down when you need to follow up.

After several calls, details can start blending together.

Having a record allows you to look back at what actually happened instead of trying to remember a conversation from several weeks ago.

Gather the Information Before Writing the Appeal

An appeal should respond to the reason for the denial.

That is difficult to do if you have not gathered the information first.

If the denial resulted from a medical necessity review, the appeal should address the specific reason the insurer determined the applicable requirements were not met.

Depending on the situation, relevant information may include:

• The denial letter

• The medical necessity criteria or medical policy used in the review

• Relevant medical records

• Treatment history

• Medication history

• Imaging or test results

• Documentation of previous treatment failures or intolerance

• A letter of medical necessity from the treating provider

• Relevant clinical guidelines or medical literature when appropriate

• Prior authorization records

• Insurance call documentation

• Applicable health plan documents

Not every appeal needs every item on this list.

More paperwork does not automatically make an appeal stronger.

The goal is to gather information that actually addresses the reason for the denial.

Being Organized Can Make the Next Step Easier

A denial can create a lot of paperwork very quickly.

You may be communicating with the insurance company, your doctor's office, medical records departments, pharmacies, imaging centers, or other healthcare providers at the same time.

This is when information that seemed unimportant several months ago can suddenly matter.

When was that medication stopped?

Where was the MRI performed?

Who did you speak with at the insurance company?

Did the provider send the requested records?

Which medical necessity criteria did the insurer say were not met?

What is the appeal deadline?

Having one place to track these details does not prove medical necessity. It does not replace your medical records, your provider's clinical documentation, or the specific evidence needed for an appeal.

And it does not guarantee that an insurance company will overturn a denial.

It simply gives you a better way to see what you know, what you still need, and what requires your attention.

You Have Options for What Comes Next

Some people want to understand the denial and manage the next steps themselves.

Others reach a point where they want help reviewing what happened, understanding the insurance process, or preparing an appeal.

Both are reasonable.

The important thing is not to assume every denial requires the same response.

Start with the denial reason.

If a medical necessity review was involved, find out what criteria were used and what requirement the insurer says was not met.

Compare that with your medical history and the documentation that was submitted.

Know your appeal deadline.

Gather the information that is actually relevant.

Then decide what your next step should be.

Prefer to Handle It Yourself?

Right to Care Solutions offers self guided resources for patients and families who want tools to help them stay organized and work through insurance issues.

The Medical Denial Checklist can help you review important information after receiving a denial so you can better understand what happened and what you may need next.

The Medical & Insurance Organizer provides one place to track appointments, medications, medical records, prior authorizations, claims and EOBs, insurance calls, bills, denials, appeals, and important follow ups.

Having those details organized before a problem occurs can make it easier to find the information you need if a prior authorization or appeal becomes necessary.

Explore Self Guided Resources →

Need More Help With a Medical Necessity Denial?

Sometimes a checklist and the right information are enough to help you determine what to do next.

Sometimes the situation is more complicated.

Right to Care Solutions provides nurse led advocacy support for patients and families dealing with prior authorizations and medical insurance denials.

Support can include reviewing the denial, helping identify the criteria or policy involved, looking for information that may need to be addressed, organizing relevant documentation, and assisting with the appeal process based on the needs of the case.

Get Help With a Medical Denial →

This article is for educational purposes and does not provide medical or legal advice. Insurance coverage, medical necessity requirements, prior authorization requirements, appeal rights, and deadlines vary by health plan and individual circumstances. Always review your denial notice and applicable plan documents for information specific to your coverage.

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