Common Denial
Reasons (and How to Fight Them)

1. Prior
Authorization Denied: “Not Medically Necessary”

What this means: Medicaid’s medical reviewer decided
you don’t need the treatment/medication your doctor prescribed.

Common examples: – Specialty medications (biologic
drugs, newer diabetes meds) – DME (wheelchairs, CPAP machines) –
Specialist visits – Procedures

How to appeal: 1. Get detailed letter from your
doctor explaining why you specifically need this (not
just “patient requests”) 2. Include medical records showing diagnosis,
previous treatments tried, why alternatives won’t work 3. Reference
Medicaid coverage policy showing it IS covered for your diagnosis

Real case – Maria, 44, Charleston:
“Medicaid denied CPAP machine for sleep apnea. Said I needed to try
weight loss first. My doctor wrote letter explaining I’d been trying to
lose weight for 2 years, sleep apnea was causing severe fatigue
affecting my job. Included sleep study showing severe apnea (AHI 42).
Appeal approved in 18 days.”

2. “Step Therapy”
Requirements Not Met

What this means: Medicaid requires you try cheaper
drugs first before approving expensive ones.

Common examples: – New diabetes medications (must
try metformin first) – Biologic drugs for arthritis (must try older
DMARDs) – Brand-name when generic exists

How to appeal: 1. Document all previous medications
tried (names, dates, duration) 2. Explain why each failed (side effects,
inadequate control, allergic reaction) 3. Include lab results or medical
notes showing failure

Real case – Tom, 58, Huntington:
“Needed Ozempic for diabetes. Medicaid said try metformin first. I’d
already tried metformin 3 years ago—had severe GI side effects, stopped
after 2 months. My doctor submitted records from 2021 showing this.
Appeal approved because step therapy was already completed.”

3. Service
Terminated: “No Longer Medically Necessary”

What this means: Medicaid approved ongoing service
(PT, home health, therapy) but now says you don’t need it anymore.

Common examples: – Physical therapy sessions – Home
health nursing – Mental health therapy

How to appeal: 1. Request appeal within 10
days to keep services during appeal 2. Get letter from provider
explaining continued medical necessity 3. Show ongoing
symptoms/functional limitations 4. Include treatment plan with specific
goals

Real case – Linda, 62, Beckley:
“Medicaid approved 20 PT sessions after hip replacement, then denied
additional sessions. My PT wrote letter showing I’d only regained 60%
range of motion, still needed walker, couldn’t climb stairs. Included
treatment goals and expected timeline. Got 12 more sessions
approved.”

4. Claim Denied:
Coding/Billing Issues

What this means: Provider submitted claim wrong
(wrong diagnosis code, wrong procedure code, etc.).

How to fix: 1. Call provider billing department –
ask them to resubmit with correct codes 2. If provider won’t fix, appeal
with correct codes and documentation

This is usually provider’s responsibility to fix,
but if they won’t, you can appeal yourself.

5. Out-of-Network Provider

What this means: You saw doctor/facility not in your
Medicaid plan’s network.

When it’s covered anyway: – Emergency care (always
covered) – No in-network provider within reasonable distance – Urgent
care when traveling

How to appeal: 1. Show there was no in-network
provider within 30 miles (or 60 minutes drive) for your specialty 2. For
emergency care, explain why you couldn’t use in-network facility 3. Get
letter from your plan confirming no in-network options

What Services WV
Medicaid Covers (for Reference)

Fully Covered (No Copay)

✅ Doctor visits (primary care and specialists)
✅ Hospital care (inpatient and outpatient)
✅ Prescriptions ($0.50-$3 copay)
✅ Lab tests and X-rays
✅ Emergency care
✅ Pregnancy and childbirth
✅ Mental health services
✅ Substance use treatment
✅ Physical/occupational/speech therapy (with prior auth)
✅ Medical equipment (wheelchairs, oxygen, CPAP – with prior auth)
✅ Transportation to medical appointments

Limited or Restricted
Coverage

⚠️ Adult dental: Emergency only (extractions,
pain/infection). No routine cleanings, fillings, or restorations.

⚠️ Vision: One eye exam per year, one pair glasses
per year. No contacts unless medically necessary.

⚠️ Chiropractic: Limited coverage (check plan)

⚠️ Weight loss: Medications for weight loss
generally not covered (except when prescribed for diabetes)

Not Covered

❌ Cosmetic procedures
❌ Experimental treatments
❌ Over-the-counter medications (unless prescribed – then sometimes
covered)
❌ Hearing aids for adults (children covered)
❌ Long-term nursing home care (different Medicaid program)

For comprehensive coverage details,
see our full WV Medicaid benefits guide →

Tips for Successful Appeals

1. Act Fast

Don’t wait. You have 60 days to appeal, but earlier
is better. If appealing service termination, file within 10 days to keep
benefits during appeal.

2. Get Doctor Involved

Doctor’s letter is critical. Generic “patient
requests” letters don’t work. Need specific medical justification: –
Exact diagnosis (ICD-10 code helps) – Why this specific treatment needed
– What alternatives were tried and failed – Clinical evidence supporting
medical necessity

3. Include Objective Evidence

Don’t just say you need it. Provide proof: – Lab
results (A1C for diabetes, lipid panel, etc.) – Imaging reports –
Functional assessments (PT notes showing limitations) – Treatment logs
(tried X medication for Y months, discontinued due to Z side effect)

4. Reference Medicaid Policy

Check if service IS covered for your diagnosis. WV
Medicaid publishes coverage policies online (dhhr.wv.gov/bms). If you
can show “Policy XYZ says condition ABC qualifies for treatment DEF,”
that’s powerful.

5. Explain Impact on Your Life

Make it real. How does denial affect you? – Can’t
work due to uncontrolled pain – Can’t care for children – Risk of
hospitalization if treatment delayed

Not just “I want this”—“Without this, I can’t function.”

6. Keep Copies of Everything

• Denial letters
• Appeal letters you send
• Supporting documents
• Notes from phone calls (date, time, person’s name)

7. Get Help If Needed

Free legal assistance:

Legal Aid of West Virginia
1-866-255-4370
wvlegalaid.org

They can help with: – Writing appeal letters – Gathering evidence –
Representing you at fair hearing

They prioritize cases involving essential medical services.

Special Situations

Emergency Care Denials

Emergency care is ALWAYS covered, even out-of-network. If denied: –
Include ER records showing emergency symptoms – Doctor statement
confirming emergency – Cite federal EMTALA law (requires Medicaid cover
emergency care)

Experimental Treatment

Medicaid doesn’t cover experimental/investigational treatments. To
appeal: – Show treatment is FDA-approved for your condition – Provide
peer-reviewed studies showing effectiveness – Doctor letter explaining
standard treatments failed

Hard to win but possible if you can show treatment isn’t truly
experimental.

Prior Authorization Taking
Too Long

If prior auth is pending and you need treatment urgently: – Request
expedited review (3 days instead of standard) – Doctor
can declare urgent medical need – If still too slow, file complaint with
WV DHHR Ombudsman: 1-877-987-3646

The Bottom Line

WV Medicaid denials are not final. You have appeal rights, and many
denials get overturned—especially when: – You have strong medical
justification from your doctor – You provide objective evidence (labs,
records, functional assessments) – You file on time and follow the
process

Success rates: – Peer-to-peer review: ~30% overturn
rate
– Written appeal: ~25% if well-documented
– Fair hearing: ~15-20%

Don’t give up after first denial. Many successful
cases went through multiple appeal levels.

Get help if you need it. Legal Aid of WV is free and
exists specifically to help low-income people navigate systems like
this.

Your health matters. Your doctor says you need this treatment.
Medicaid said no. You have the right to fight back.

Download Appeal Letter Template: [Request via email
to member services]