A denial that says "not medically necessary": what the notice must include

Federal and Texas rules list what a written denial must contain. This page sets out those lists by plan type, so a letter can be checked against them. It does not judge whether any care is needed. That is for the patient and the doctor.

Job-based plans, and Marketplace and other ACA plans

The notice must be written "in a manner calculated to be understood by the claimant" and must give (29 CFR 2560.503-1(g)(1)):

1. "The specific reason or reasons for the adverse determination";
2. "Reference to the specific plan provisions on which the determination is based";
3. a description of any added material needed to perfect the claim, and why;
4. the plan's review steps and time limits. For job-based plans, this includes the right to bring a civil action under section 502(a) of ERISA after an appeal;
5. the internal rule, guideline, protocol or criterion relied on, or a statement that one was used and that a copy is free on request;
6. for a medical-necessity denial, "an explanation of the scientific or clinical judgment for the determination", or a statement that it is free on request;
7. for an urgent claim, a description of the expedited process.

Insured group plans and individual plans must meet the same list (45 CFR 147.136(b)(2)(i), (b)(3)(i)).

Added items for ACA plans

Under 45 CFR 147.136(b)(2)(ii)(E), the notice must also include:

• information to identify the claim (the date of service, the provider, and the amount if any), and a statement that the diagnosis and treatment codes and their meanings are available on request;
• "the denial code and its corresponding meaning, as well as a description of the plan's or issuer's standard, if any, that was used in denying the claim";
• a description of internal appeals and external review, including how to start an appeal;
• contact details for any consumer assistance office or ombudsman.

Older "grandfathered" plans are generally outside these added items (45 CFR 147.136(a)(1)(ii)).

Texas-regulated plans ("TDI" or "DOI" on the card)

The Texas rule says the notice must include "the principal reasons", "the clinical basis", "a description or the source of the screening criteria", and "the professional specialty of the physician" who made the decision. Further items cover the complaint, appeal and outside-review steps (28 TAC 19.1709(c)).

Medicare Advantage plans

The notice must "State the specific reasons for the denial" (42 CFR 422.568(e)(2)). From January 1, 2026, a prior-authorization denial "must include a specific reason for the denial" (42 CFR 422.122(a)).

What the appeal review must look like (job-based plans)

• It gives no deference to the first decision, and it is decided by someone who is neither the person who made the first decision nor that person's subordinate (29 CFR 2560.503-1(h)(3)(ii)).
• For a medical-judgment denial, the plan must consult a health care professional with "appropriate training and experience in the field of medicine involved", who was not consulted on the first decision ((h)(3)(iii), (v)).
• The plan must identify the medical advisers whose advice it obtained ((h)(3)(iv)).

When the notice leaves something out

• A missing criterion or clinical explanation can be asked for, free (29 CFR 2560.503-1(g)(1)(v)). A separate page explains how to ask for the claim file.
• In ACA plans, if the plan does not "strictly adhere" to the internal-appeal rules, the claimant may go straight to external review. Small errors made in good faith do not count, and the rule sets out that exception (45 CFR 147.136(b)(2)(ii)(F)).

Free public help

• The plan's member line, printed on the card.
• Texas Department of Insurance: 800-252-3439.
• Office of Public Insurance Counsel (OPIC), the state office that speaks for insurance consumers: 1-877-611-6742.
• Texas Medicare help line: 800-252-9240.

What Denial Reply prepares

Denial Reply prepares appeal paperwork for Texas adults from the denial letter and records. The packet starts with a one-page summary of what the letter states: the reason, the plan type and the dates. The free decoder at /decode needs no upload.

Related guides: asking for the claim file and criteria · which kind of plan you have · federal outside review

Sources

• 29 CFR 2560.503-1: https://www.law.cornell.edu/cfr/text/29/2560.503-1 (read 2026-11-03)
• 45 CFR 147.136: https://www.law.cornell.edu/cfr/text/45/147.136 (read 2026-11-03)
• 28 TAC 19.1709: https://www.law.cornell.edu/regulations/texas/28-Tex-Admin-Code-SS-19-1709 (read 2026-11-03)
• 42 CFR part 422 (2025 edition): https://www.govinfo.gov/content/pkg/CFR-2025-title42-vol3/xml/CFR-2025-title42-vol3-part422.xml (read 2026-11-03)