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Medical necessity denial

Denied as “not medically necessary”? A physician can answer that.

A licensed physician reads your records, decides whether your case has merit, and writes the letter that answers your plan on its own clinical terms.

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No account needed to check. A physician tells you candidly if the case has no merit.

What this denial means

“Not medically necessary” is an opinion, and opinions can be answered.

When a plan denies care as not medically necessary, it is saying its written criteria were not met by the paperwork in front of it. That paperwork is usually a fraction of your chart: a claim form, a code, perhaps a short note. The reviewer rarely sees how your illness has moved, what you have already tried, or why your treating physician chose this option.

That gap is where an appeal does its work. Your plan's criteria are written down, and so is the clinical evidence behind your treatment. Setting the two side by side, in the plan's own language, is work that takes a clinician, which is exactly who Cove Health puts on your case.

What the letter argues

Written by a licensed physician, cited line by line.

Your record, in full

The history the reviewer never saw: diagnoses, prior treatments and how each one turned out, and the way the condition has progressed.

The plan's own criteria

Your plan publishes the medical-necessity criteria it applied. The letter walks them point by point and shows where your case meets them.

Guidelines and evidence

Specialty-society guidelines, labeling and peer-reviewed literature supporting the treatment your physician ordered. Each one cited, so nothing rests on assertion.

Why the alternative does not fit

Where the plan points to a cheaper or more conservative option, the letter explains clinically why it is not appropriate for you.

Medication guides

Denied a specific medication?

Compounded medications denied: what plans cover and what they do notCompounded drugs sit outside the usual formulary rules, and most denials are about the compound itself rather than your clinical case. Here is what the criteria ask for and when an appeal has something to work with.compounded semaglutidecompounded tirzepatidecompounded topical pain creamsRead the guide →Dupixent and skin biologics denied: eczema, psoriasis and asthmaDenials of Dupixent, Skyrizi and the other dermatology and respiratory biologics usually rest on how severity was documented. Here is what the criteria ask for and how an appeal answers them.DupixentSkyriziTremfyaRead the guide →Off-label prescriptions denied: when a plan says the use is not approvedOff-label prescribing is legal and common, and coverage policies usually point to specific compendia and guidelines. Here is how an appeal identifies the support a plan's own policy recognises.off-label oncology regimensoff-label psychiatric prescribingoff-label pediatric dosingRead the guide →Oral cancer drugs denied: targeted therapies and oral chemotherapyOral oncology denials often turn on biomarker documentation, line of therapy, or a use the plan reads as off-label. Here is what an appeal has to show, and how urgency is put on the record.IbranceVerzenioImbruvicaRead the guide →

Browse every medication guide →

After the internal appeal

If your plan denies the appeal, your state has a next step.

External review sends the decision to clinicians who do not work for your plan. Who runs it, and how long you have to ask, depends on where you live: we keep a page for each of the 51 states and the District of Columbia, linked to the regulator's own filing page.

Find external review in my state →

Resources

Not ready to start a case? That’s okay. Start here.

Start hereYour insurance denied a medication or treatment: what to do in the next 48 hoursA denial letter starts a clock. Here is what to read, what to request, and what to gather in the two days after it arrives, in the order it usually matters.Read the Guide →

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Getting started

From your denial letter to a physician-signed appeal, in four steps.

Tell us what happened

Share your denial and some basic information about the medication or treatment your doctor recommended. Don’t worry if you don’t know exactly what kind of denial you have.

We review your case

A licensed Cove Health physician reviews your information, the reason for the denial, and the medical and coverage criteria that may apply to your case.

We build the case for your care

Your Cove Health physician uses medical evidence, clinical guidelines, and Cove Health’s technology to develop a clear, well-supported case for the care your doctor recommended.

We help you take the next step

We help you understand what comes next and advocate on your behalf based on the needs of your case.

Appeal deadlines are set by your health plan and/or applicable law, and you remain responsible for meeting them. Submitting a case does not guarantee that an appeal can be completed or filed before your deadline unless Cove expressly confirms otherwise.

Simple, honest pricing

One issue or many, we've got you.

Single Case

One issue, fully handled: review, drafting, and advocacy.

$100 flat fee

✓ Licensed physician review of your records
✓ One fully drafted, guideline-cited advocacy letter
✓ Sent to the party of your choice
✓ No subscription, no commitment

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Best for ongoing needs

Cove Membership

For patients juggling multiple issues across plans and providers.

$29.99 / month

Two-month minimum, then month to month

✓ Ongoing advocacy across multiple issues
✓ Priority physician review
✓ Unlimited letters while subscribed
✓Continuous case tracking & follow-ups

Become a member

The membership starts with a two-month minimum commitment. If you cancel during those first two months, the remaining balance for the commitment is still due and will be charged. After the initial two months it continues month to month until you cancel.

Cove Health provides non-legal patient advocacy. We are not a law firm and do not provide legal representation.

Frequently asked questions

Medical necessity denials, answered.

What does “not medically necessary” actually mean on my denial? +

It means the plan's reviewer concluded that the care your physician ordered did not meet the plan's written coverage criteria for your situation. It is not a finding that the care is useless or unsafe, and it is not your treating physician's judgment. It is the plan's, made from limited records.

Can a medical necessity denial be appealed? +

Yes. Plans are required to offer an internal appeal, and most patients also have a right to review by an independent external reviewer if the internal appeal fails. The deadlines and the address are printed on your denial letter, and those are the authority on your case.

Does Cove Health replace my doctor? +

No. Your treating physicians keep directing your care. Our physician's role is advocacy: assembling the record and the guidelines into a letter that argues, on clinical grounds, for the care your doctor already recommended.

What if my case does not have merit? +

We tell you candidly before writing anything. We would rather say so than send a letter we do not believe in, and where we can we will point you toward avenues that fit your situation better.

How quickly do I need to act? +

Sooner than most people expect. Internal appeal windows are commonly 180 days from the date of denial, and expedited review exists where waiting would put your health at risk. Check the deadline printed on your own denial letter first.

Still have a question?

Common insurance problems

Facing a different denial?

“Your care needs approval first.”Prior authorizationYour insurer requires approval before it will cover your medication or treatment, and that approval has been delayed or denied.How Cove Health can help →“You need to try something else first.”Step therapyYour insurer requires you to try another medication or treatment before it will cover the one your doctor recommended.How Cove Health can help →“Your medication isn’t covered.”Formulary exceptionYour medication may not be on your insurance plan’s covered drug list, or your insurer may require an exception before it will cover it.How Cove Health can help →

Next step

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