In medical necessity denials and appeals, which statement is correct?

• A. If a service is deemed not medically necessary, plans can deny coverage; there is no appeal.
• B. If a service is deemed not medically necessary, patients and providers can appeal with evidence and peer reviews to overturn denial.
• C. Denials cannot be overturned through appeals.
• D. Appeals are decided solely by plan medical directors with no evidence.

Answer: (B)

Medical necessity denials include an appeal pathway that allows reevaluation when a service is denied. Patients and providers can submit additional medical evidence—records, physician notes, guidelines—and have the decision reviewed, often with a peer comparison to standard criteria. If the new evidence demonstrates that the service meets the plan's medical necessity criteria, the denial can be overturned. External independent reviews may also be available if internal appeals don’t resolve the issue. Denials can be overturned through the appeal process; decisions are not made solely by plan medical directors without evidence, and there is typically an opportunity to present evidence and have peer input.