When you’re facing a serious illness or injury, the last thing you should worry about is whether your insurance company will cover the treatment your doctor says you need. Unfortunately, for many patients, that’s precisely what happens. One of the most common tactics health insurers use to deny coverage is claiming a treatment is “not medically necessary.”
On the surface, this term sounds clinical and objective. But in reality, “medical necessity” is often misinterpreted or manipulated by insurers to justify denying expensive—but essential—care.
What Does “Medically Necessary” Mean?
Generally, medical necessity refers to services or treatments that are appropriate, effective, and required for diagnosing or treating a health condition. However, each insurance company has its internal guidelines for what it considers medically necessary—and those definitions are often vague, outdated, or profit-driven.
Insurers may reject claims for:
- FDA-approved medications
- Life-saving cancer treatments
- Surgeries recommended by specialists
- Mental health therapies
- Treatments for chronic pain or rare diseases
Even when your doctor submits extensive documentation proving that treatment is necessary, insurance companies may deny the claim based on their narrow criteria.
How Insurance Companies Use This to Their Advantage
Insurance companies are businesses. Their goal is to minimize costs, even if it means putting patients at risk. By labeling treatments as not medically necessary, they shift the burden to the patient and force many people to abandon care due to financial strain.
They may also:
- Use internal medical reviewers who never examine the patient
- Rely on generic care guidelines that don’t account for individual cases
- Delay decisions to wear patients down
- Deny appeals automatically without a thorough review
These tactics can delay crucial treatments—or prevent them altogether.
You Have the Right to Fight Back
Just because an insurer claims a treatment isn’t necessary doesn’t make it accurate. You have the right to appeal the decision, submit additional documentation, request an Independent Medical Review (IMR), and—when necessary—take legal action.
At The Law Offices of Scott Glovsky, we’ve spent decades helping patients stand up to insurance companies that act in bad faith. We understand the medical and legal complexities behind these denials—and we fight to ensure our clients get the life-saving care they were promised.
If your health insurance company has denied a treatment by calling it “not medically necessary,” don’t face it alone. Contact The Law Offices of Scott Glovsky for a free consultation. We’re here to hold insurers accountable—and help you get the care you need and deserve.