Service Not Covered

What Strengthens Your Appeal

• ✓Evidence that the service is an Essential Health Benefit required under the ACA (for marketplace and small employer plans)
• ✓State mandated benefit laws that require coverage for certain services (e.g., fertility treatment in some states, autism treatment, etc.)
• ✓Evidence that the service was covered in prior plan years (implying plan design changes)
• ✓Documentation that the service is medically necessary and not merely cosmetic or elective
• ✓Evidence that the exclusion is ambiguous and should be interpreted in your favor under contra proferentem doctrine

Appeal Packet: What to Include

• 1Denial letter citing the specific exclusion provision
• 2Your plan documents showing the exclusion language
• 3ACA Essential Health Benefits categories if relevant
• 4State mandate documentation if your state requires coverage
• 5Physician letter documenting medical necessity
• 6Prior EOBs if the service was previously covered

What to Ask Your Doctor or Provider

Your provider plays a key role in your appeal. Ask them for:

• →A Letter of Medical Necessity emphasizing the clinical need for the service
• →Documentation of what happens if the service is not covered (clinical consequences)

Step-by-Step Escalation

If your first appeal fails: File a state insurance complaint citing ACA essential health benefit requirements or state mandate violations. For employer self-funded plans, contact the Department of Labor. Coverage exclusions that violate federal or state law can be challenged successfully.

Procedure-Specific Not Covered Guides

Related Denial Reasons