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Coverage Denial

Meaning

Coverage denial is a formal decision by a health insurance provider to refuse payment for a specific medical service, procedure, prescription, or device requested by a patient or their clinician. This determination indicates that the proposed treatment does not meet the insurer’s established criteria for medical necessity, is considered experimental, or is explicitly excluded under the terms of the patient’s health plan contract. Understanding the specific reason for denial is the first step in addressing this common clinical barrier.