Blue Cross Blue Shield Medical Necessity Denied: How to Appeal

Why Blue Cross Blue Shield Denies Medical Necessity Claims

Blue Cross Blue Shield denies medical necessity denied claims when it determines the request does not meet its internal coverage criteria. This may involve a medical necessity determination, a prior authorization requirement, a network limitation, or a policy exclusion.

Common Denial Reasons

• Not medically necessary: Blue Cross Blue Shield's clinical reviewers determined the service did not meet coverage criteria
• Prior authorization not obtained or denied: Advance approval was required but not received
• Out-of-network provider: The treating provider or facility is not in Blue Cross Blue Shield's network
• Plan exclusion: The service is excluded under your specific Blue Cross Blue Shield plan
• Missing documentation: Insufficient clinical records were submitted to support the claim

Steps to Appeal

1. Get the denial in writing — Request Blue Cross Blue Shield's denial letter with the specific reason and policy provision cited
2. Request the clinical policy document — Blue Cross Blue Shield must provide the internal criteria applied to your claim
3. Obtain a letter of medical necessity — Your treating physician should directly address the denial reason
4. File an internal appeal — Submit within 180 days of the denial notice. Urgent appeals must be processed within 72 hours
5. Request external review — If the internal appeal fails, request independent external review. Blue Cross Blue Shield must comply under federal ACA rules

Documents Required

• Blue Cross Blue Shield denial letter and Explanation of Benefits (EOB)
• Treating physician's letter of medical necessity
• Clinical records supporting the denied service
• Blue Cross Blue Shield's clinical policy bulletin for the denied service
• Published clinical guidelines (specialty society recommendations)

Frequently Asked Questions

Q: How long do I have to appeal a Blue Cross Blue Shield Medical Necessity denial? A: Standard internal appeals: 180 days from the denial notice. Urgent/expedited appeals: 72 hours.

Q: Can Blue Cross Blue Shield deny my appeal without a doctor reviewing it? A: No. Appeal reviews must be conducted by a licensed clinician with relevant specialty expertise.

Q: What if my internal appeal is denied? A: Request independent external review. External reviewers are independent of Blue Cross Blue Shield and reverse insurer decisions in a significant percentage of cases.