Even when doctors say it’s needed, insurers often say no.
You did everything right. You saw your doctor, followed their advice, and submitted the paperwork. Then, out of nowhere, you’re told your treatment isn’t covered because it’s “not medically necessary.”
Wait—who gets to decide what’s necessary?
Here’s the disturbing truth: health insurance companies often override doctors, deny care, and hide behind vague definitions of “medical necessity.” It’s a strategy that helps them save money—while leaving patients confused, frustrated, and in pain.
“Medical Necessity” Sounds Clinical—But It’s Often Political
On the surface, “medical necessity” seems like a rational concept. Of course insurers shouldn’t pay for treatments that are unsafe or ineffective, right?
But in practice, “not medically necessary” has become a catch-all excuse—one that insurers can twist to deny coverage for care that trained doctors deem critical.
Your doctor may recommend:
- A diagnostic scan
- A surgery
- A specialist referral
- A prescription for a newer, more effective drug
And yet, your insurer might reject it. Not because it’s unsafe. Not because it won’t help. But because they don’t want to cover the cost.
Who Makes the Call? (Hint: Not Your Doctor)
When an insurer says a treatment isn’t necessary, that decision usually isn’t made by a doctor who has examined you. Often, it’s made by:
- Company-employed nurses following strict checklists
- Algorithm-based systems reviewing codes
- Remote doctors in other states who’ve never seen your medical file
- Administrative staff trained to “triage” claims and flag anything expensive
In short, people who don’t know your condition are determining your care.
When profits drive decisions, “medical necessity” becomes a weapon—not a safeguard.
Real People, Real Harm
Let’s look at what happens when insurers misuse “medical necessity”:
- A teen with severe scoliosis is denied spinal surgery because the curve isn’t “severe enough”—even though her orthopedic surgeon strongly disagrees.
- A man with debilitating depression is denied psychiatric treatment because the insurer doesn’t cover more than 10 sessions. “Further treatment not deemed necessary.”
- A cancer patient’s PET scan is denied because the insurance algorithm didn’t recognize the latest oncology guidelines.
These aren’t just clerical errors. They are calculated cost-saving strategies—and they carry real consequences.
Insurers Count on You Giving Up
When you get that “denied due to medical necessity” letter, you have a right to appeal. But insurers bet that you won’t. Why?
Because:
- Appeals take time
- Policies are written in legalese
- You’re already sick, tired, and overwhelmed
And they’re right. Most people don’t appeal—even when the denial is clearly wrong.
But here’s what they won’t tell you: a significant percentage of appeals get approved. They just hope you never find that out.
So What Can You Do?
Here’s how to fight back when you’re told your treatment isn’t medically necessary:
1. Request the Explanation in Writing
Insurers are required to give a detailed reason for denial. Don’t settle for vague statements—get specifics.
2. Ask for a Peer-to-Peer Review
Your doctor can request a direct call with the insurer’s reviewing physician. This puts a medical professional in your corner.
3. File a Formal Appeal
Most plans must allow at least one internal and one external appeal. Use both. Don’t let them wear you down.
4. Get Help from an Advocate
Patient advocacy groups, hospital billing advocates, or even your state’s Department of Insurance can support your fight.
5. Go Public
If you feel like your story represents a larger injustice, tell it. Social pressure and media coverage can create change.
“Medical Necessity” Should Protect Patients—Not Profits
We need to reclaim this phrase. “Medically necessary” should reflect the judgment of your doctor, not a spreadsheet in a corporate office.
The abuse of this term is a silent crisis in American healthcare. It delays treatment. It denies dignity. And it defends a system where your health is secondary to their bottom line.
💬 Have you or someone you know been denied care due to so-called medical necessity? Share your story below. We’re listening.
