Switch to ADA Accessible Theme
Close Menu
Gianelli & Morris
We Fight Insurance Companies and Win
Home > Practice Areas > Denials Based on Medical Necessity

Health Insurance Claims Denied Based on Medical Necessity


When you are dealing with a serious illness or injury, you are looking for treatment and a cure.  When your doctor recommends a course of treatment, you want to follow your doctor’s recommendation.  If you have been on top of paying your health insurance premiums, you expect that your insurer will be on your side. You need medical treatment now, and you have been paying them up to this point with the expectation that they will cover you when you need it.  Health insurers such as Anthem Blue Cross and Blue Shield of California, unfortunately, are often looking for any reason they can drum up to deny your coverage.

Is Your Insurer Using “Medical Necessity” as an Excuse to Wrongfully Deny Your Claim?

Health insurance providers often rely on “medical necessity” when denying insurance claims.  They will tell you that your policy does not cover healthcare services that are not medically necessary and will disagree with your physician about what services you need for your medical issue.  Proving medical necessity in response to a coverage denial can be a difficult and complex affair.  The California bad faith insurance denial lawyers at Gianelli & Morris are here to help.

The Definition of Medical Necessity Depends on the Type of Insurer

Health insurance companies provide coverage only for healthcare services that are medically necessary.  In general, medical necessity means that the service is necessary for diagnosis or treatment and that the services meet accepted standards in the medical community for medical practice and treatment. However, Private insurers without Medicare plans can define medical necessity for themselves, establishing their own criteria.  Medicare plans use national and local coverage determination standards that define medical necessity, and they are required to provide coverage in accordance with the rules set by federal and state law.

Standard Definitions of Medical Necessity

Generally, medical necessity is defined as any reasonable service, procedure, or treatment that will reduce the effects of an illness or condition, prevent the onset of a condition, or aid a person in regaining full functional capacity.  Insurers prefer you to take the approach that is the least invasive and most economically conservative.  If you are going in for invasive, expensive surgery, insurers want to know that less invasive, less costly procedures such as therapy or drugs are not feasible.

Treatments that are not generally accepted in the medical community are more likely to be rejected as unnecessary.  For example, treatments, services, or pharmaceuticals that are not approved by the FDA are more likely to be deemed medically unnecessary.

Don’t Let Your Insurer Reject Your Doctor’s Sound Judgment

Importantly, there may not be (and often there is not) one specific treatment that is “necessary” in a given situation.  If your doctor recommends a course of treatment to get you back to full health, and that treatment is generally accepted by the medical community, your health insurance should cover the treatment.  Your doctor may have good reason to recommend the more expensive drug or the more costly, time-consuming treatment.  Your health and well-being are what matter most.

If your insurer denies your treatment on the grounds it is not necessary, you should not take that denial lying down.  The insurance company does not know better than your doctor what you need.  Get a dedicated health insurance lawyer on your side to help you file an appeal and fight for the coverage that you deserve.

Fight For Your Right to Medical Care With a Strong-Willed Legal Champion On Your Side

Arguing against a health insurance company that wrongfully denied your insurance claim requires a tough, experienced, and passionate legal team.  You will be up against a large corporation with significant legal resources.  If you are taking on a health insurance company, you need a law firm in your corner that knows the law and knows how to fight.  You can depend on the California health insurance attorneys at Gianelli & Morris.  Our bad faith insurance denial legal team understands everything that is at stake in your case, and we will work tenaciously on your behalf to secure the best possible result.

Call 213-489-1600 today for a free consultation.

Share This Page:
Facebook Twitter LinkedIn
Designed and Powered by NextClient

© 2021 - 2024 Gianelli & Morris, A Law Corporation. All rights reserved.
Custom WebShop™ law firm website design by NextClient.com.


It appears you don't have Adobe Reader or PDF support in this web browser. Click here to download the PDF.