Medical Necessity Explained

Understanding “Medical Necessity”

“Medically necessary” sounds straightforward, but in the world of health insurance, it’s anything but.
Every insurance company, Medicare plan, and Medicaid program defines it a little differently — often in ways that protect their bottom line, not your health.

At its core, medical necessity means a service, medication, or treatment that is reasonable, necessary, and appropriate for your condition — not just because it helps you feel better, but because it meets certain criteria written into your plan’s policy.

For example:

• Medicare defines medically necessary services as those that are “needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

• Private insurance often adds requirements like “proven effective,” “supported by peer-reviewed literature,” or “not primarily for convenience.”
  
  

Unfortunately, these vague definitions allow insurers to deny claims even when treatments clearly help.

Why Insurers Deny “Medically Necessary” Care

Common reasons for denial include:

• The treatment is “experimental or investigational.”

• The medication is “not FDA-approved for your diagnosis.”

• The therapy is “not covered under your plan’s definition of medical necessity.”

• The insurer claims there are “alternative covered options.”

In reality, these denials often ignore your unique medical history and the individualized judgment of your doctor.

How to Prove Medical Necessity

You can fight back — and win. Here’s how:

1. Gather Documentation

Collect everything that supports your need:

• Provider notes explaining your diagnosis and response to treatment

• Prior authorization requests and denial letters

• Medication lists and treatment history

• Peer-reviewed studies showing effectiveness for your condition

• Letters of Medical Necessity (LMNs) from your doctor or specialist

2. Use the Insurer’s Language

When appealing, use the exact terms from your policy.
If your plan defines medical necessity as “clinically appropriate, evidence-based, and not primarily for convenience,” quote that definition back to them and show how your treatment meets it.

3. Provide Comparative Evidence

If you’ve tried other treatments that failed or caused side effects, document it.
Explain why your current treatment (e.g., a compounded medication like Low Dose Naltrexone) is the only option that’s both effective and safe for you.

4. Include Professional Support

Ask your provider and pharmacist to include:

• Diagnostic codes (ICD-10)

• Specific dosage and formulation details

• Clinical rationale and references

Their professional endorsement carries weight.

5. Stay Persistent

Denials are designed to make you give up. Don’t.
Appeal every step — from internal review to the Independent Review Entity (IRE), and if needed, to an Administrative Law Judge (ALJ) hearing. Many patients win when they persist.

The Bottom Line

Medical necessity isn’t just a definition — it’s the heart of every healthcare coverage battle.
Proving it takes persistence, documentation, and the right language — but you don’t have to face it alone.

AKG Advocacy exists to help patients like you build strong cases, educate your providers, and hold insurers accountable.