Insurance Advocacy Guide: Network Inadequacy & Medical Necessity

The key is to frame everything in their language: medical necessity, network inadequacy, and risk.

Below are the strongest points to make, roughly in order of impact.

1. Network inadequacy (this is the big one)

This is usually the most successful argument.

Emphasize that:

• No in-network providers are available within a reasonable distance or timeframe

• In-network providers:

  • Are not accepting new patients

  • Have waitlists that are clinically inappropriate (e.g., 8–12+ weeks)

  • Do not respond to contact attempts

• The insurer’s directory is inaccurate (very common)

Helpful phrasing:

“The plan’s network does not offer reasonably accessible providers able to meet the member’s clinical needs.”

📌 Tip: If you can, document names, dates, and outcomes of attempts to find in-network care. Even a short list helps a lot.

2. Provider has unique or specialized expertise

Especially powerful for mental health.

Argue that the out-of-network provider offers:

• A specialized modality (e.g., EMDR, DBT, trauma-informed care, eating disorder treatment, autism-informed therapy, culturally competent care)

• Experience with a specific diagnosis or comorbidity not adequately treated by in-network providers

• Language, cultural, or identity-affirming competence that’s clinically relevant

Example framing:

“The member requires a provider with specialized training in [X], which is not available within the plan’s network.”

This is stronger when tied to treatment failure with more general care.

3. Continuity of care / risk of disruption

Insurers hate risk—even more than cost.

Highlight:

• The patient has already established a therapeutic relationship

• Progress is being made

• Changing providers could:

  • Cause clinical regression

  • Increase symptoms

  • Increase risk of crisis, hospitalization, or self-harm

Key phrases they listen to:

• “Disruption of care”

• “Clinical deterioration”

• “Increased risk of higher-level services”

Example:

“Transitioning care at this stage presents a significant risk of destabilization.”

4. Medical necessity (tie everything back to this)

Every argument should loop back to this phrase.

Support with:

• Diagnosis (without oversharing)

• Symptom severity

• Functional impairment

• Prior treatment history and outcomes

You’re aiming for:

“This level and type of care is medically necessary and cannot be met in-network.”

5. Cost-effectiveness (counterintuitive, but effective)

Sometimes it helps to remind them that denying this can cost more.

Point out that approval may:

• Prevent ER visits or inpatient hospitalization

• Prevent repeated failed treatment attempts

• Reduce long-term claims costs

This works best when framed calmly, not as a threat.

6. Parity & regulatory pressure (use lightly but confidently)

You don’t need to threaten lawsuits—but you can signal awareness.

References that help:

• Mental Health Parity and Addiction Equity Act (MHPAEA)

• State network adequacy requirements

Example:

“Given the lack of accessible in-network options, denial may raise parity and network adequacy concerns.”

This often nudges cases into “approve to avoid hassle” territory.

Practical tips that improve approval odds

• Ask for a “single-case agreement” or “single-use exception” by name

• Have the provider submit a supporting letter if possible

• Escalate politely to a supervisor or care manager

• If denied, ask for the denial in writing and appeal—it genuinely works