The Most Commonly Denied Medical Procedures in 2025: How to Get the Care You Need When Insurers Say No
"I'm sorry, but your insurance has denied your surgery request."
These words hit James Morgan like a physical blow. For months, he had endured debilitating back pain that radiated down his leg, making simple tasks like putting on socks or picking up his grandson impossible. After exhausting conservative treatments—physical therapy, pain medications, steroid injections—his orthopedic surgeon recommended a spinal fusion. Yet his insurance company deemed the procedure "experimental" despite it being a well-established treatment performed thousands of times daily across the country.
James's experience isn't unusual. Every day at CounterForce Health, we meet patients caught in similar situations—prescribed treatments their doctors believe necessary but their insurers refuse to cover. According to comprehensive analysis from the Kaiser Family Foundation, nearly one in five in-network claims (19%) submitted to Healthcare.gov insurers was denied in 2023, with even higher rates for certain procedures and treatments.
"What makes these denials particularly frustrating is that they often contradict medical expertise," explains Dr. Sarah Johnson, Medical Director at CounterForce Health. "We regularly see patients denied procedures that represent the standard of care for their condition, forcing them to navigate a complex appeals process while their health deteriorates."
This growing problem affects millions of Americans across all types of insurance—private plans, Medicare Advantage, and Medicaid managed care. Understanding which procedures face the highest denial rates and why insurers reject them gives patients the knowledge they need to fight back effectively. After helping thousands overcome inappropriate denials, we've identified the most commonly rejected procedures and the strategies that consistently work to reverse these decisions.
The Six Procedures Insurers Most Frequently Deny
Back and Spine Surgeries: High-Cost Treatments Under Intense Scrutiny
When Elizabeth Chen first consulted a neurosurgeon about her chronic back pain and numbness in her right leg, she had already tried everything else—physical therapy, chiropractic care, acupuncture, and multiple pain management approaches. MRI results showed severe spinal stenosis and a herniated disc compressing her nerve roots. Her surgeon recommended a laminectomy and fusion, explaining it was the appropriate next step given her symptoms and imaging results.
Yet Elizabeth's insurer denied the procedure, claiming she hadn't adequately explored conservative treatments despite her six-month history of failed therapies. This pattern is increasingly common. The American Academy of Orthopaedic Surgeons has documented denial rates exceeding 30% for spinal procedures, even when recommended by qualified specialists after conservative approaches have failed.
"Insurance companies have created an increasingly difficult gauntlet for spine surgery patients," notes Dr. Robert Chen, neurosurgeon at Massachusetts General Hospital. "We're seeing patients with clear surgical indications—progressive neurological deficits, debilitating pain, and structural problems visible on imaging—being denied necessary care based on generic protocols that don't consider individual circumstances."
The denials typically claim "lack of medical necessity" or "insufficient evidence of effectiveness," despite substantial research supporting these procedures for appropriate patients. Many insurers require documentation showing months of failed conservative treatments before considering surgical intervention, creating scenarios where patients endure prolonged suffering while waiting to "fail enough" to qualify.
However, these denials can be successfully fought. According to the North American Spine Society, approximately 60% of spine surgery appeals succeed when properly documented. Elizabeth eventually secured approval after her surgeon participated in a peer-to-peer review with the insurance company's medical director, presenting her complete treatment history and explaining how her specific nerve compression required surgical intervention that couldn't be addressed through continued conservative care.
"The key to my approval was having my surgeon advocate directly with the insurance company," Elizabeth recalls. "He explained exactly how my case met their own criteria for surgery, using their terminology and addressing their specific concerns rather than just restating my symptoms."
Mental Health Services: The Treatment Gap Widening Despite Parity Laws
David Ramirez struggled with severe depression for years before finally seeking help. When his symptoms worsened to include suicidal thoughts, his psychiatrist recommended an intensive outpatient program (IOP) that would provide daily therapeutic support while allowing him to continue working. Despite clear medical documentation of David's deteriorating condition, his insurer denied coverage, claiming he should try more weekly therapy sessions before qualifying for intensive treatment.
"They wanted me to continue with an approach that clearly wasn't working," David says. "My psychiatrist explained that delaying appropriate care increased my risk, but the insurance company seemed more concerned with their standard protocol than my actual needs."
Mental health services face significantly higher denial rates than physical health treatments, despite parity laws intended to prevent such discrimination. The Mental Health America 2024 Access to Care Report found that over 56% of youth with major depression received no mental health treatment at all, with insurance barriers being a primary contributing factor.
The denial patterns for mental health services follow distinct patterns. Insurers routinely reject coverage for intensive outpatient programs, residential treatment, extended therapy beyond arbitrary session limits, and specific evidence-based therapies for conditions like PTSD or eating disorders. These denials typically cite vague reasons like "not meeting medical necessity criteria" or "insufficient documentation," without specific guidance about what would constitute acceptable evidence.
The American Psychological Association has documented how some insurers use proprietary and non-transparent criteria for mental health approvals that are more restrictive than generally accepted clinical standards. This creates situations where treatments widely considered appropriate by mental health professionals are routinely denied by insurers using different standards.
After connecting with a patient advocate who specialized in mental health parity cases, David filed an appeal citing specific violations of federal parity laws. His appeal documented how his insurer applied more restrictive standards to mental health treatment than they used for comparable medical conditions. Within three weeks, his denial was reversed and he began the intensive outpatient program his psychiatrist had recommended.
"What worked was framing the appeal around parity law violations rather than just restating my symptoms," David explains. "Once we showed that their denial process for mental health didn't match their process for physical health conditions, they quickly approved the treatment."
Advanced Imaging Studies: Diagnostic Delays with Serious Consequences
When Maria Gonzalez discovered a lump in her breast, her primary care physician ordered a mammogram, which showed an area of concern. Her doctor then recommended an MRI for further evaluation, explaining that it would provide more detailed information needed to determine whether the mass was cancerous and guide treatment planning if necessary.
Despite the clear medical indication, Maria's insurance denied the MRI as "not medically necessary," suggesting an ultrasound should be performed first. This delay tactic for advanced imaging is increasingly common. According to research published in the Journal of the American College of Radiology, approximately 15-20% of advanced imaging studies—MRIs, CT scans, and PET scans—are initially denied, even when ordered by specialists for appropriate indications.
"These imaging denials can have serious consequences," explains Dr. Jennifer Williams, radiologist at Johns Hopkins Hospital. "When advanced imaging is delayed, diagnosis and treatment planning are also delayed. For conditions like cancer, these delays can impact prognosis and treatment options."
Insurance companies typically require extensive documentation showing that less expensive imaging options like X-rays or ultrasounds have been tried first or would be insufficient. While step therapy approaches may make sense in some contexts, they can be inappropriate when a physician has determined that advanced imaging is specifically needed based on clinical findings.
A study by Harvard Medical School found that delays in advanced imaging due to insurance barriers resulted in an average diagnostic delay of 24 days for serious conditions, with some patients experiencing delays exceeding two months while appealing denials.
Maria's primary care physician submitted a detailed appeal explaining why an MRI was specifically indicated based on the mammogram findings and her risk factors. The appeal included relevant sections of the American College of Radiology guidelines for breast imaging, which supported MRI as an appropriate next step based on her specific presentation. After a peer-to-peer review, the MRI was approved.
The MRI revealed a malignancy that might have been missed with less sensitive imaging, allowing Maria to begin treatment promptly. "I'm grateful my doctor fought for the right test," Maria says. "Without the MRI, we might not have caught my cancer at such an early stage when it's most treatable."
Colonoscopies and Preventive Screenings: Coverage Gaps Despite Legal Requirements
When Michael Peterson scheduled his routine colonoscopy at age 50, he believed it would be fully covered as preventive care under the Affordable Care Act. Instead, he received a bill for over $2,000 after the procedure when his insurer reclassified the colonoscopy from "screening" to "diagnostic" because the doctor had removed several small polyps during the examination.
"I was shocked," Michael recalls. "I did exactly what public health guidelines recommend by getting screened, and then received a huge bill for doing the right thing. It made me wonder if I should have skipped the screening entirely."
Despite the Affordable Care Act's requirement that preventive services be covered without cost-sharing, many patients encounter unexpected barriers to colonoscopies and other screening procedures. The issue often arises from how these procedures are classified.
When a colonoscopy shifts from "screening" to "diagnostic" (for example, if a polyp is removed during what was initially intended as a screening procedure), many insurers attempt to apply cost-sharing requirements. This practice contradicts guidance from the Centers for Medicare & Medicaid Services, which has clarified that polyp removal is an integral part of a screening colonoscopy and should not change how the procedure is covered.
"This bait-and-switch tactic discourages people from getting potentially life-saving screenings," says Dr. Thomas Garcia, gastroenterologist at the Cleveland Clinic. "Many patients who receive unexpected bills for what should be covered preventive care tell me they'll think twice before getting their next recommended screening."
The American Cancer Society reports that confusion over coverage has contributed to screening rates remaining below public health targets, potentially missing early cancer diagnoses when treatment would be most effective. Their research shows that approximately 40% of patients who receive bills for what should be covered preventive screenings choose to delay or avoid future screenings.
Michael eventually resolved his situation by filing an appeal citing specific language from both the Affordable Care Act preventive services provisions and guidance from federal regulators clarifying that polyp removal during a screening colonoscopy should not change its preventive classification. The appeal succeeded, and his insurer reprocessed the claim without cost-sharing.
"I learned that you have to know your rights under the law," Michael says. "The insurance company was counting on me not understanding the difference between how they classified the procedure and what the law actually requires."
New and Specialized Medications: Barriers to Effective Treatment
When Sophia Garcia was diagnosed with rheumatoid arthritis at age 35, her rheumatologist recommended a biologic medication based on her specific disease presentation and risk factors for rapid progression. Despite clear documentation of her diagnosis and the medical rationale for the specific treatment, her insurer denied coverage, insisting she first try and fail on two older medications—a process that would take at least six months while her disease potentially caused permanent joint damage.
"It felt like they were forcing me to get worse before I could get better," Sophia recalls. "My doctor explained that waiting could mean irreversible damage to my joints, but the insurance company seemed more concerned with their standard protocol than my individual medical situation."
Specialty medications—particularly those for conditions like rheumatoid arthritis, multiple sclerosis, cancer, and rare diseases—face extremely high denial rates. The Arthritis Foundation reports that biologics and other advanced treatments face initial denial rates of up to 50%, even when specifically recommended by specialists based on individual patient factors.
Insurance companies typically require extensive "step therapy" protocols, forcing patients to try and fail on multiple older, less expensive medications before approving newer treatments. While step therapy may be appropriate in some circumstances, these one-size-fits-all approaches often ignore individual patient factors that may make certain patients poor candidates for older treatments or at high risk for disease progression while waiting through multiple medication failures.
"Step therapy protocols can be particularly harmful for patients with aggressive disease or high risk for rapid progression," explains Dr. Maria Gutierrez, rheumatologist at NYU Langone Health. "There are identifiable patient subgroups who are unlikely to respond to conventional therapies and will experience irreversible damage while going through required medication failures."
Sophia and her rheumatologist developed a comprehensive appeal that included several key elements: medical literature supporting early biologic therapy for patients with her specific disease markers, documentation of factors indicating high risk for rapid progression, and a personalized risk assessment detailing the potential consequences of delayed appropriate treatment. The appeal specifically addressed the insurer's step therapy protocol and explained why exemption was medically appropriate in her case based on her disease presentation.
After a peer-to-peer review where her rheumatologist explained these factors directly to the insurance company's medical director, the denial was overturned and Sophia began biologic therapy without having to first fail on medications her doctor believed inappropriate for her situation.
"What worked was having my doctor explain exactly why my case warranted an exception to their standard protocol," Sophia explains. "The appeal wasn't just about my diagnosis in general, but about why my specific situation made their standard approach inappropriate."
Understanding Why Insurers Deny These Procedures
While each patient's denial may seem unique, patterns emerge when examining insurance denials across different procedures and companies. Understanding these patterns helps develop more effective appeals.
"Insurance companies use remarkably similar language and reasoning across different types of denials," explains Sarah Rodriguez, healthcare lawyer at CounterForce Health. "Once you recognize these patterns, you can develop targeted counter-arguments that address the real basis for denial rather than arguing points the insurer isn't actually disputing."
The most common justification for denials is a determination that a procedure is "not medically necessary." However, insurers and physicians often use different standards for this determination. The American Medical Association has documented how insurance companies frequently use outdated or proprietary criteria that don't align with current clinical practice guidelines. These criteria may be more restrictive than what most medical specialists consider appropriate care.
Many denials stem from technical rather than clinical issues. According to a report by Experian Health, approximately 46% of denials in 2024 were due to missing or inaccurate data, authorization issues, or incomplete patient information. These "technical denials" have nothing to do with whether the procedure is appropriate for the patient, yet they can delay or prevent necessary care.
Insurance companies also frequently deny procedures by classifying them as "experimental" or "investigational" even when they've been in widespread clinical use for years. This designation allows insurers to exclude coverage under policy provisions that explicitly don't cover unproven treatments, even when substantial scientific evidence supports their use.
Some denials occur because care was received from out-of-network providers or facilities, even when patients had limited or no choice in the matter. The Commonwealth Fund found that out-of-network claims face a denial rate of 37%, nearly double the rate for in-network services. While the No Surprises Act now protects patients from many of these billing scenarios, insurers may still initially deny claims that should be covered.
"What many patients don't realize is that initial denials are often automatic or based on cursory reviews," Rodriguez explains. "Insurance companies know that many people will simply accept the denial rather than navigate the complex appeals process. Persistence and properly structured appeals can overcome many inappropriate denials."
The Five Strategies That Consistently Reverse Denials
Despite these challenges, patients can successfully fight insurance denials. Our experience at CounterForce Health shows that well-crafted appeals succeed approximately 40-60% of the time, with even higher success rates for certain procedures and situations.
After helping thousands of patients secure coverage for initially denied procedures, we've identified five strategies that consistently work across different types of denials:
Document Medical Necessity with Compelling Clinical Evidence
James Morgan's spinal fusion was initially denied despite clear evidence of spinal stenosis and nerve compression on his MRI. His successful appeal included comprehensive documentation that went beyond simply restating his diagnosis and symptoms.
"We built a complete case file that told my story from multiple angles," James explains. "It included my imaging results with key findings highlighted, detailed notes showing how my symptoms correlated with the imaging findings, documentation of all failed conservative treatments with specific dates and durations, and functional assessments showing how my condition prevented specific activities of daily living."
The most successful appeals include objective evidence whenever possible—imaging results, lab values, standardized assessment scores, and measurable functional limitations. This creates a clear, evidence-based foundation for the medical necessity argument that's difficult for reviewers to dismiss.
James's surgeon also provided a detailed letter explaining the specific anatomical issues visible on the MRI and how they related to James's symptoms. The letter referenced current clinical guidelines from the North American Spine Society supporting surgery for patients with his specific presentation after failing conservative treatment.
"The combination of objective evidence and expert interpretation made the medical necessity clear even to non-specialist reviewers," James notes. "It wasn't just my word against theirs—it was documented evidence interpreted by medical experts."
Align Your Appeal with Clinical Guidelines and Medical Standards
When Rebecca Williams was denied coverage for residential treatment for anorexia nervosa despite reaching a dangerously low weight, her successful appeal centered on alignment with established clinical guidelines.
"My initial appeal just emphasized how sick I was and how outpatient treatment wasn't working," Rebecca recalls. "The successful appeal took a different approach—it specifically cited treatment guidelines from the American Psychiatric Association and showed exactly how my situation met their criteria for residential treatment."
Clinical guidelines represent consensus among medical experts about appropriate care for specific conditions. Citing these guidelines in appeals demonstrates that you're not asking for unusual or inappropriate treatment, but rather care that aligns with established medical standards.
Rebecca's appeal included specific sections from the American Psychiatric Association's guidelines on eating disorders, highlighting the criteria for higher levels of care and demonstrating how her vital signs, lab values, and failed outpatient treatment history met these criteria. The appeal also referenced research studies supporting residential treatment for patients with similar presentations.
"Framing the appeal around established guidelines shifted the conversation from opinions to evidence," Rebecca explains. "It wasn't just my doctor's judgment against the insurance reviewer's—it was about whether they were following recognized standards of care."
Master the Appeals Process and Hierarchy
Carlos Rodriguez was initially denied coverage for a specialized medication for his rheumatoid arthritis. After two failed appeals through his insurer's internal process, he requested an external review by independent medical experts.
"The external review made all the difference," Carlos says. "Unlike the insurance company reviewers, the independent physicians applied current medical guidelines rather than the insurer's restrictive criteria. They approved the medication within two weeks of receiving my case."
Most patients don't realize that insurance appeals involve multiple levels, each with different reviewing entities and success rates. Understanding this hierarchy and strategically navigating it significantly increases overall success rates.
The initial internal review is typically conducted by the insurance company's staff and often focuses on administrative requirements and basic medical criteria. These reviews have the lowest success rates, typically around 30-40%.
If the internal review upholds the denial, patients can usually request a medical director review, where a physician employed by the insurer evaluates the case. This level provides an opportunity for peer-to-peer discussions between the treating physician and the insurance company's medical director, with success rates of 50-60% when properly prepared.
External or independent review by clinicians not employed by the insurance company is required by law in most states for final appeal determinations. These reviews apply broader medical criteria rather than insurer-specific guidelines and have success rates of 40-60%, often higher for certain procedures.
"The key is persistence through multiple appeal levels," Carlos advises. "My first two appeals were denied, but the external review approved my medication because they used different, more current medical criteria than the insurance company's internal reviewers."
Facilitate Effective Physician Advocacy
Maria Gonzalez's denied MRI was ultimately approved after her physician participated in a peer-to-peer review with the insurance company's medical director. During this conversation, her doctor explained exactly why an MRI was necessary based on her specific mammogram findings and risk factors.
"Having my doctor speak directly with their doctor completely changed the dynamic," Maria explains. "She was able to answer specific questions about my case and address their concerns in real-time rather than through written documentation that might be misinterpreted."
Physician advocacy substantially increases appeal success rates. According to the American Medical Association, appeals that include direct physician involvement have success rates approximately 2.5 times higher than those without physician participation.
Effective physician advocacy goes beyond general statements about medical necessity. The most successful physician interventions specifically address the insurer's stated reasons for denial, explain why the recommended procedure is appropriate based on current medical evidence, and detail the potential consequences of denial or delay.
"My doctor prepared for the peer-to-peer review by reviewing the specific criteria the insurance company used for approving MRIs," Maria notes. "She was able to explain exactly how my case met each of their requirements, which made it difficult for them to maintain the denial."
Know and Assert Your Legal Rights and Protections
Michael Peterson's colonoscopy was initially classified as diagnostic rather than preventive when polyps were removed during the procedure, resulting in significant cost-sharing requirements that should not have applied under the Affordable Care Act.
"I didn't just accept the bill," Michael explains. "I researched the legal requirements for preventive care coverage and discovered that federal regulators had specifically addressed this issue, clarifying that polyp removal during a screening colonoscopy shouldn't change its preventive classification."
His successful appeal cited specific language from Department of Health and Human Services guidance documents and referenced the exact sections of the Affordable Care Act that applied to his situation. The appeal also included an explanation of how the insurer's practices contradicted these legal requirements.
Several laws and regulations protect patients from inappropriate insurance denials, and citing these protections can significantly strengthen appeals:
The Affordable Care Act's preventive care provisions require coverage without cost-sharing for many screening procedures. Mental Health Parity laws prohibit more restrictive coverage for mental health conditions compared to physical health. The No Surprises Act protects patients from many out-of-network bills. State-specific insurance regulations often include additional consumer protections beyond federal requirements. ERISA establishes requirements for employer-sponsored plans, including specific appeal procedures.
"Legal and regulatory arguments often succeed where purely medical arguments fail," Michael advises. "When the insurance company realizes they're potentially violating regulations rather than just making a questionable medical judgment, the dynamic changes completely."
The Path to Successful Appeals
These five strategies work best when combined into a comprehensive approach. Sophia Garcia's successful appeal for her rheumatoid arthritis medication integrated all these elements:
She documented medical necessity with comprehensive clinical evidence, including specific lab values showing high inflammatory markers, imaging results demonstrating early joint damage, and functional assessments quantifying her limitations.
Her appeal aligned with clinical guidelines by specifically citing the American College of Rheumatology guidelines for rheumatoid arthritis treatment and demonstrating how her case matched their criteria for biologic therapy.
She navigated the appeals process strategically, beginning with a detailed written appeal and proceeding to a peer-to-peer review when the initial appeal was denied. She also prepared for external review if necessary, though this proved unnecessary after the peer-to-peer succeeded.
Her rheumatologist provided effective advocacy by participating directly in the peer-to-peer review, explaining the specific factors that made Sophia a poor candidate for conventional therapy and a high risk for rapid progression without appropriate treatment.
The appeal asserted her legal rights by referencing state insurance regulations regarding step therapy protocols and citing the requirement that insurers consider individual patient factors when applying standardized protocols.
"What worked wasn't any single element, but rather the combination of approaches," Sophia explains. "The comprehensive documentation established the facts, the clinical guidelines provided the standards, my doctor's direct involvement addressed specific concerns, and the legal references reminded them of their obligations under the law."
This integrated approach turned what initially seemed like an insurmountable denial into an approval that allowed Sophia to begin appropriate treatment before her disease caused permanent damage.
What to Do If You've Been Denied
If you've recently received a denial for a recommended medical procedure, don't accept it as the final word on your care. Take these immediate steps to begin the appeals process:
Request a complete explanation of the denial in writing, including the specific criteria used and any alternative treatments the insurer would cover. Some denials are vague or incomplete, making effective appeals difficult without understanding the exact basis for rejection.
Collect comprehensive documentation from your healthcare providers, including medical records, test results, and a detailed letter explaining why the procedure is medically necessary for your specific situation. This documentation provides the foundation for your appeal.
Research relevant clinical guidelines from medical societies and government health agencies that support the recommended procedure for your condition. These guidelines represent medical consensus and can be powerful evidence in appeals.
Speak with your physician about participating directly in the appeals process, including writing a detailed letter and potentially participating in a peer-to-peer review with the insurance company's medical director. Physician advocacy significantly increases appeal success rates.
Consider seeking professional assistance if the denial involves complex medical or legal issues, or if initial appeals have been unsuccessful. Organizations like CounterForce Health specialize in navigating insurance appeals for denied medical procedures.
Remember that persistence is key—many successful appeals require multiple levels of review before coverage is approved. The Patient Advocate Foundation reports that approximately 60% of patients who persist through all available appeal levels eventually secure coverage for initially denied procedures.
"The biggest mistake I see patients make is giving up after the first denial," says Dr. Thomas Garcia, gastroenterologist at the Cleveland Clinic. "Insurance companies count on a certain percentage of patients accepting denials without appeal. By persistently advocating for appropriate care, patients can often overcome inappropriate denials and access the treatments they need."
Your Health Is Worth Fighting For
While insurance denials for medical procedures have become increasingly common, they are not the final word on your healthcare. By understanding why specific procedures are denied, gathering appropriate documentation, and navigating the appeals process strategically, you can significantly increase your chances of securing the care you need.
At CounterForce Health, we believe that patients should receive the treatments their physicians recommend based on medical evidence and individual circumstances—not arbitrary insurance policies. Our experience has shown that informed, persistent advocacy can overcome many inappropriate denials.
If you're facing an insurance denial for a recommended procedure, don't give up. Your health is worth fighting for, and with the right approach, you can successfully challenge denials and access the care you need.
This guide is provided for informational purposes only and does not constitute legal or medical advice. Individual insurance policies and circumstances vary, and results cannot be guaranteed. For personalized assistance with your insurance appeal, visit CounterForce Health or consult with a qualified healthcare advocate or attorney.