What does missing medical necessary criteria mean? And can you appeal it?

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  • Jul 09,2018
  • 8 answers

What does missing medical necessary criteria mean? And can you appeal it?


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Insurance Answers (8)

Flying Ferret 2 months ago

It means one of two things: (1) important information necessary to make a medical decision has not been provided; or (2) the required criteria to get a medical-treatment decision in your favor haven't been met.
The first means "we can't make a decision without more information"; there's no decision to appeal.
The second means "we've decided not to give you what you want"; that's a decision you can try to appeal.

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amy lynn 2 months ago

It means there is not enough medical proof that the required test or required procedure is actually needed.
The doctor needs to provide more proof to the insurance company that the test or procedure he is trying to get pre-approved is truly the only test or procedure that will work for what you need.

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babyboomer1001 2 months ago

It doesn't mean anything. It is a jumbled major typo.

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champer 2 months ago

At a guess, this is your insurance company declining to pay for something. It means that they don't see it as medically necessary, and therefore won't pay. The phraseology means you miss the criteria they require to make it medically necessary. Talk to them about it.

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STEVEN F 2 months ago

It means you didn't supply the medical information required for whatever you are applying for.
There is NOTHING to appeal. You either provide the required information, or they CAN'T process your application.

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Pascal the Gambler 2 months ago

It means you didn't qualify for something because you didn't submit enough info or your medical condition doesn't qualify.

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Rosalie 2 months ago

Go back to your doctor's staff and ask for help. That phrase means you didn't have the things they look for to match up to having a claim, and the medical staff may not have worded it the right way, or they may be able to add more information to help you qualify. Insurance companies do their best to get out of paying for anything they don't have to, and sometimes you have to tailor the claim to their system. If your situation was supposed to have been covered, go back to your doctor's office staff for help.

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David 14 2 months ago

It means the criteria is missing. By definition you can't appeal a decision that hasn't been made.

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