Common use of Your Right to Appeal A Determination that A Service Is Not Medically Necessary Clause in Contracts

Your Right to Appeal A Determination that A Service Is Not Medically Necessary. If Fidelis has denied coverage on the basis that the service is not medically necessary, you may appeal to an External Appeal Agent if you satisfy the following two (2) criteria: • The service, procedure or treatment must otherwise be a Covered Service under the Subscriber Contract; and • You must have received a final adverse determination through Fidelis’ internal appeal process and Fidelis must have upheld the denial or you and Fidelis must agree in writing to waive any internal appeal.

Your Right to Appeal A Determination that A Service Is Not Medically Necessary. If Fidelis has denied coverage on the basis that the service is not medically necessary, you may appeal to an External Appeal Agent if you satisfy the following two (2) criteria: •  The service, procedure or treatment must otherwise be a Covered Service under the Subscriber Contract; and •  You must have received a final adverse determination through Fidelis’ internal appeal process and Fidelis must have upheld the denial or you and Fidelis must agree in writing to waive any internal appeal.