What it means
When an insurer asks whether a service is medically necessary, they are reviewing whether the service is clinically appropriate for the patient's situation based on diagnosis, symptoms, prior treatment, accepted standards of care, and the documentation submitted by the provider.
What it does NOT mean
It is not a judgment of whether you personally need care. The reviewer is comparing the submitted documentation to written policy criteria, often using tools like MCG or InterQual. If the documentation is incomplete, the decision can go against you even if the care is genuinely needed.
What to ask your provider
Ask your provider's office to confirm which diagnosis codes were sent, whether prior conservative treatment is documented in the chart, and whether the prior authorization request includes the most recent exam notes and imaging.
If the request is denied
Most insurers offer at least one level of internal appeal, and many states require an external review option. Ask your insurer in writing for the specific policy criteria that were not met, and ask your provider to write a letter of medical necessity that addresses each point directly.