What should be done if a claim is denied for medical necessity?

• A. Pay the balance and move on.
• B. An appeal letter should be sent along with additional supporting reports.
• C. The claim should be immediately re-billed without any changes.
• D. Denials cannot be appealed.

Answer: (B)

When a claim is denied for medical necessity, the action to take is to file an appeal with additional supporting documentation that shows why the service was medically necessary. The payer’s denial usually means the initial submission didn’t demonstrate alignment with their medical-necessity criteria, so providing more detailed clinical justification helps overturn the decision.

An effective appeal letter should clearly tie the patient’s diagnosis and symptoms to the proposed service, and reference the payer’s specific policy or coverage criteria. Attach updated or new documentation that supports the claim, such as physician notes, treatment plans, test results, imaging reports, and current clinical guidelines or literature that back the necessity of the service. Include the claim number, dates of service, and a concise narrative from the clinician linking the patient’s condition to the recommended treatment.

This approach directly addresses the payer’s reason for denial and uses new or clarified evidence to show that the service meets coverage criteria. Paying the balance, re-billing without changes, or assuming a denial cannot be appealed do not address the underlying issue and are not the appropriate steps in this situation.