When Insurance Denies Your Surgery or Treatment
Having a surgery or a course of treatment denied as not medically necessary is the most common health denial there is, and the most frustrating, because your own doctor recommended the treatment and someone who has never met you decided otherwise.
First: where did your coverage come from?
If this coverage came through an employer, federal law may govern it — which changes your appeal rights, imposes deadlines that are strict, and can displace the state remedies described here. Establish that before deciding how to fight a denial.
How the determination is actually made
A reviewer applies the plan's clinical criteria to the records submitted. That means two things are challengeable: which criteria were applied, and what records the reviewer actually had. Denials frequently rest on an incomplete file rather than on a genuine clinical disagreement.
Ask what was reviewed, and by whom
Request the criteria relied on, the reviewer's specialty, and the list of records considered. A reviewer without relevant specialty training, or one who did not have the notes that explain why the treatment was recommended, is a specific and answerable problem.
The treating physician's role
A letter that engages with the plan's own criteria — point by point, explaining why this patient meets them — does considerably more than a letter asserting the treatment is necessary. Give your doctor the criteria and the denial, not just the news that it was denied.
What you can do about it depends on your state
This describes the denial itself, which works much the same everywhere. Whether you can sue under a statute, what you can recover, and how long you have differ sharply — choose the state where your policy was issued.
Common questions
My doctor says I need it. Is that not enough?
Not by itself, unfortunately. The appeal works best when your doctor addresses the plan’s own clinical criteria directly rather than restating the recommendation.
Can I find out who reviewed my case?
You can ask for the reviewer’s credentials and specialty, along with the criteria applied and the records considered. It is a reasonable request and the answer is often useful.
Is this what happened to you?
A free, confidential review can tell you whether the denial holds up — no cost, no obligation.
Other reasons claims get denied
General information, not legal advice. Insurance law differs by state and every policy is different.