My health plan says the care wasn't medically necessary. What do I do, step by step, and by when?

Health insuranceDeniedChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: GovInfo · 29 CFR § 2560.503-1 «Claims procedure: notice content» · paragraph (g)(1)(v) View original ↗

In short

If the plan says the care was not needed, it must explain why, or tell you how to get that for free.
Ask for the reason, the rules it used, and your claim file.
Appeal within 180 days. If that fails, ask for an outside review.

What this means

Plans use their own medical rules to decide what care is «needed». When they deny care for this reason, the federal rule says the notice must explain the medical reason, or say you can get that explanation free [1].

You can also get your claim file free on request [2]. An employer group plan must give you at least 180 days after you receive the notice to appeal [3]. For urgent care, a group health plan that provides for one appeal must decide on review within 72 hours [4]. The external review process must allow at least four months after the notice to ask for it [5]. The federal process has no charge. A state process or a contracted review company may charge, and the charge can't be more than $25 [6].

Your next step

Ask the plan in writing for your claim file, which must be free on request [2], and for the medical reason in the notice [1]. Send your appeal within the time on the notice; an employer group plan must give you at least 180 days after you receive it [3]. After a final denial, ask for an outside review; the process must allow at least four months [5].

Check it yourself

Open HealthCare.gov, «External review», at https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ and read the part quoted above. Your plan's own notice and rules apply to you: "Don't know yet" for your case.

Where this comes from (6)

[1] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: notice content» · paragraph (g)(1)(v) · checked 2026-11-06
determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request
[2] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: appeal rights» · paragraph (h)(2)(iii) · checked 2026-11-06
Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits
[3] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: appeal time» · paragraph (h)(3)(i) · checked 2026-11-06
Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination
[4] GovInfo · 29 CFR § 2560.503-1 «Time for the decision on review» · paragraph (i)(2)(i)–(iii) · checked 2026-11-06
In the case of a claim involving urgent care, the plan administrator shall notify the claimant, in accordance with paragraph (j) of this section, of the plan's benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claimant's request for review of an adverse benefit determination by the plan … In the case of a pre-service claim…
[5] GovInfo · 45 CFR § 147.136 «External review: time frames» · external review process · checked 2026-11-06
at least four months after the receipt of a notice of an adverse benefit determination or final internal adverse benefit determination for a request for an external review to be filed … within no more than 45 days after the receipt of the request for external review by the IRO … As expeditiously as possible but within no more than 72 hours after the receipt of the request for expedited external review by the IRO
[6] HealthCare.gov · checked 2026-11-06
If your health insurance company is using the HHS-Administered Federal External Review Process, there's no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge can't be more than $25 per external review … Call toll free: 1-888-866-6205 to request an external review request form

How we found this

We matched your question to 6 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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