The short answer
If your doctor recommends a test or treatment your plan does not cover, your doctor and the hospital billing team can help you seek approval, often with a letter explaining why the care is needed. If the plan still says no, you can use its appeals process.
Start by learning which tests, treatments, and drugs your plan covers.
If care is not covered, your doctor can write a letter explaining why it is needed.
You submit that letter to the insurance company to ask for approval.
If the plan still says no, you can go through its appeals process.
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The full explanation.
The simple version
Sometimes a doctor recommends a test or treatment that your insurance plan does not cover. That can feel discouraging, but it is not always the end of the road. There are clear steps you can take to ask your plan to approve the care, and people whose job is to help you take them.
First, find out what is covered
Before care begins, it helps to know what your plan covers. The National Cancer Institute suggests calling your insurance company and asking a benefits coordinator which tests, treatments, and drugs are covered, and whether your plan will cover specialists your doctor refers you to. Knowing this early means fewer surprises.
Getting approval before treatment
If your doctor feels you need a test or procedure that your insurance does not cover, your doctor and the hospital billing department can help you take the steps to seek approval. This is about asking your plan, ahead of time, to agree to cover the care.
Your doctor's office and billing team are your partners in getting care approved.
The role of your doctor's letter
A common step is for your doctor to write a letter stating why the test or procedure is needed. You then submit this letter to the insurance company. The letter helps the plan understand why your doctor believes the care is important for you.
If the answer is still no: appeals
If the company does not agree to cover the treatment or procedure, you can go through its appeals process — the steps a plan offers for asking it to reconsider. Your plan materials and any denial letter explain how appeals work, including deadlines to meet. Keeping copies of everything you send and receive makes this easier.
Who can help
You do not have to manage this alone:
- your doctor's office can provide medical information and write letters
- the hospital billing department can explain the steps
- a hospital social worker or financial counselor can help you understand your options and prepare paperwork
A denial is not always the final word — asking for help early makes the next steps clearer.
Ask for a case manager
You can ask your insurance company to assign you a case manager. That way you speak with the same person each time you call about approval or coverage, instead of explaining your situation from the start to someone new. It can make a slow process feel a little more manageable.
Keep good records along the way
Whether you are seeking approval or filing an appeal, keep copies of everything you send and receive, and note the details of your phone calls — who you spoke with, the date, and what they said. If a claim is denied, your denial letter will explain the reasons and the steps to appeal, including deadlines to meet. Good records make each step easier and help you keep track of what is due when.
A note before we begin
This information is educational and is not a substitute for medical, legal, or financial advice. For your own situation, talk with your care team, your plan, or a hospital social worker.
Reviewed sources
This article is based on public information from the National Cancer Institute:
Words to know
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Common questions
▸What if my insurance will not cover a treatment my doctor recommends?
Your doctor and the hospital billing department can help you take steps to get it covered. Often the doctor writes a letter stating why the test or procedure is needed, which you submit to your insurance company. If the company does not agree, you can go through its appeals process.
▸What goes in the doctor's letter?
The letter explains why your doctor believes you need a test or procedure that your plan does not currently cover. It is part of asking the insurance company to approve and pay for the care.
▸What happens if the plan still says no?
You can use the plan's appeals process to ask it to reconsider. Reading your plan materials and any denial letter will explain the steps and deadlines to follow.
▸Who can help me with this?
Your doctor's office and the hospital billing department can guide you. A hospital social worker or financial counselor can also help you understand your options and prepare paperwork.
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