Letter of Medical Necessity: How to Get One That Optimizes Your Chance of Success

Letter of Medical Necessity: How to Get One That Optimizes Your Chance of Success

Legally reviewed By Scott Glovsky in Insurance and Healthcare Denials

When your health insurance company denies treatment as not medically necessary, you may find yourself caught between two very different opinions. Your treating physician, who knows your medical history and has examined or treated you, believes you need the care. Your insurer has reached a different conclusion based on its review of the request and the medical criteria it applies.

A letter of medical necessity gives your treating physician an opportunity to explain why the recommended treatment is appropriate for you. But simply asking your doctor to write that the treatment is “medically necessary” may not be enough.

That disagreement is important. An insurance company’s medical necessity determination is not the same thing as your treating physician’s medical judgment. A useful letter should address your individual medical circumstances and, whenever possible, respond directly to the reason your health plan gave for denying coverage. If you are challenging a medical necessity denial in California, knowing what to ask your doctor to include can help you build a more complete appeal.

If your health insurer has denied treatment as not medically necessary, speaking with an experienced health insurance denial lawyer like Scott Glovsky can help you understand the insurer’s reasoning and your options for challenging the decision. Call or contact us online to schedule a free consultation.

What Is a Letter of Medical Necessity?

A letter of medical necessity is documentation from a physician or other treating healthcare professional explaining why a particular treatment, medication, test, procedure, or medical service is necessary for a patient.

The letter may be submitted as part of a prior authorization request or used to support an appeal after coverage has been denied.

The most effective letters do more than confirm a diagnosis and recommend treatment. They connect the requested care to the patient’s medical history, previous treatment, current condition, and the clinical reasons the provider believes the treatment is necessary.

If the health plan has already issued a denial, the letter should also address the insurer’s stated reason for refusing coverage.

What Should a Medical Necessity Letter Look Like?

If you are searching for a medical necessity letter template, focus less on finding the perfect form and more on the information your physician should communicate. A strong letter should be specific to your medical history, the treatment being requested, and, if coverage has already been denied, the reason your insurer denied coverage.

When a denial identifies a particular medical policy or clinical criterion, the physician should review that information before preparing the letter. This allows the physician to address the insurer’s reasoning directly rather than simply restating that the recommended treatment is medically necessary.

A well-organized letter may include:

• Patient and insurance information. Include the patient’s name, member or subscriber ID, and applicable claim or authorization number.
• The requested treatment. Clearly identify the recommended medication, procedure, test, or other service.
• Diagnosis and relevant medical history. Explain the medical circumstances that led to the treatment recommendation.
• Previous treatment. Describe what has already been tried, how the patient responded, and why other options may not be appropriate.
• The insurer’s reason for denial. Address the medical policy, clinical criteria, or other explanation provided by the health plan.
• The physician’s medical reasoning. Explain why the requested treatment is medically necessary for this patient and respond to the insurer’s stated concerns.
• Supporting medical evidence. Include relevant clinical guidelines, medical literature, test results, or other documentation when appropriate. California’s Independent Medical Review program considers factors such as peer-reviewed scientific and medical evidence, nationally recognized professional standards, expert opinion, and generally accepted standards of medical practice when evaluating medical necessity.
• The consequences of delaying care. When applicable, explain how delaying or denying treatment could affect the patient’s condition.
• A clear request. State whether the physician is requesting initial approval of the treatment or reconsideration of a denial.

For example, if the health plan says the patient must first try another treatment, the physician can explain that the patient already tried it, that it failed, or that the patient’s medical condition makes the alternative inappropriate. If the insurer characterizes a treatment as experimental or investigational, the physician can address the medical evidence supporting the recommended care.

The letter doesn’t need to be lengthy, just thorough. What matters is whether it gives the insurer a clear medical explanation for why the requested care is appropriate for you and directly addresses the issue that led to the denial.

Is a Letter of Medical Necessity Enough to Overturn a Denial?

Not necessarily. A detailed physician letter can provide important medical evidence, but it does not guarantee that an insurance company will reverse its decision.

The outcome may depend on the reason for the denial, the terms of the health plan, the insurer’s medical criteria, the supporting medical necessity documentation, and the applicable review process.

A letter of medical necessity should therefore be viewed as one part of the medical record used to challenge the denial, not as the appeal itself. The insurer’s stated reason for denying coverage, its medical policy, your physician’s explanation, your medical records, and supporting scientific evidence may all become important when challenging the decision. For qualifying medical disputes, California patients may also have the right to request an Independent Medical Review if the health plan continues to deny the requested care.

Your Doctor Says You Need the Treatment. Your Insurer Says You Don’t.

When those two positions collide, the details matter. A strong letter of medical necessity can help explain why your doctor recommends a particular treatment, but challenging a denial may require looking closely at the insurer’s reasoning, its medical policy, your records, and the review options available under your health plan.

For more than three decades, Scott Glovsky has helped Californians challenge health insurance companies when medically necessary care is denied. If your insurer has refused to cover treatment your doctor recommends, contact the Law Offices of Scott Glovsky or call 626-243-5598 to discuss the denial and your options.

Official Resources Used to Inform This Page

To ensure the accuracy and clarity of this page, we referenced official resources during the content development process:

• Independent Medical Review (IMR)
• California Department of Managed Health Care (DMHC)