The letter names a policy number but did not include the document. Do they have to send it?

On request, yes, and free of charge. Where an internal rule, guideline, protocol, or other similar criterion was relied on in a group health plan's adverse determination, the notice must give either the criterion itself or a statement that it was relied on plus a promise that a copy will be provided free of charge on request (29 CFR 2560.503-1(g)(1)(v)(A), read 22 August 2026). The same requirement is repeated for the decision on appeal at (j)(5)(i). Most letters take the second option, which means the copy exists and is waiting on a written request. Separately, where the denial rests on medical necessity, the plan owes you an explanation of the scientific or clinical judgment applying the plan's terms to your medical circumstances, again either up front or on request ((g)(1)(v)(B)).

The insurer says its criteria are MCG or InterQual and licensed. Does that end the request?

It changes how the document reaches you, not whether it has to. UnitedHealthcare states publicly that it may use third-party tools such as the InterQual criteria, and Anthem states it is licensed to use MCG guidelines and may customize them through its Medical Policy & Technology Assessment Committee (both pages read 22 August 2026). Neither vendor publishes the full guideline set. But the federal duty at 29 CFR 2560.503-1(g)(1)(v)(A) attaches to the specific criterion relied on in your determination, not to whoever wrote it, and plans commonly produce the relevant excerpt rather than the library. A flat refusal to produce anything is a strict-adherence problem under 45 CFR 147.136(b)(2)(ii)(F), which can deem the internal process exhausted.

Which version of the policy applies, the one on the website today or the one from my date of service?

The one relied on in making the determination, which for a claim already adjudicated means the version in force on the date of service. Insurer libraries publish both dates: UnitedHealthcare's commercial medical policy listing shows a 'Last Published' date and a separate 'Effective Date' for each policy (read 22 August 2026). Because policies are revised on a rolling basis, ask in writing for the version relied on, identified by effective date, rather than assuming the current PDF is the one that governed your claim.

I have Medicare Advantage. Is there a public criteria document for my denial?

There should be, and the rule is unusually specific. An MA organization may create internal coverage criteria only where coverage criteria are not fully established in Medicare statutes, regulations, NCDs, or LCDs, and where it does, it must make publicly accessible the internal coverage criteria in use, a summary of the evidence considered during their development, a list of the sources of that evidence, and an explanation of the rationale supporting their adoption (42 CFR 422.101(b)(6) and (b)(6)(ii), read 22 August 2026). So for an MA denial the first question is whether an NCD or LCD already covers the item, which you can check yourself in the Medicare Coverage Database.

Find the Criteria Behind a 'Not Medically Necessary' Denial

A "not medically necessary" denial is not an opinion somebody formed about you. It is the output of a comparison that finished before the letter was printed: a numbered list of conditions, held in an internal document, run against whatever paperwork was in the file that day. One side of that comparison was mailed to you. The other side was not.

So the letter cites the document instead of enclosing it — CPB 0016, or CG-SURG-97, or 2026T0514X, same type size as everything around it, no link, no attachment. Until you hold what that string points at, you are arguing with a conclusion and guessing at the premises. Getting it is a written request rather than a favour, and two paragraphs of federal regulation say so.

Sourcing first: the regulatory text quoted here is the eCFR as it stood on 22 August 2026, and the insurer policy libraries were opened the same day and quoted rather than summarised. Whether a treatment was right for you is not a question this page touches — that belongs to the clinician who treated you, and the best use of the document you are about to go and get is to put it in front of that person.

Harvest four strings before you write anything

Put the denial letter and the explanation of benefits side by side and copy out four things, exactly as printed.

The policy identifier. A bulletin number, a guideline code, a title, or a vendor name. It may sit in a footnote, on a line labelled reference, or in a sentence beginning based on.
The procedure and diagnosis codes. The CPT or HCPCS code is what the policy is indexed by. If the codes are not printed, the plan owes them on request, and asking is not itself an appeal (45 CFR 147.136(b)(2)(ii)(E)(1) and (2)).
The date of service. This decides which version of the policy is the real one.
The denial sentence, verbatim, plus the CARC printed on the EOB.

The letter was supposed to name a standard on its own. The reason given must include the denial code and its meaning "as well as a description of the plan's or issuer's standard, if any, that was used in denying the claim" (45 CFR 147.136(b)(2)(ii)(E)(3)), and on a final internal determination it must include a discussion of the decision. A letter naming no standard has a gap worth citing, and the order to read the letter in shows what else is missing.

Four libraries, and the trap in the date column

Most large commercial insurers publish their medical policies openly, no login, indexed by number.

Insurer	Where the library sits	How policies are labelled
Aetna	Medical Clinical Policy Bulletins	Four-digit CPB number; URLs are predictable, e.g. `aetna.com/cpb/medical/data/400_499/0466.html`
UnitedHealthcare	Commercial medical and drug policies	Title, effective and last-published dates, procedure codes in the summary line
Anthem / Elevance	Medical policies and clinical UM guidelines	Two separate shelves — medical policies, and clinical UM guidelines — listed apart
Cigna	Medical and administrative A–Z index	Alphabetical, four-digit policy number in parentheses after each title

Search by procedure code, not by the name of the treatment. Names drift. Codes do not.

Now the part that eats a month. UnitedHealthcare's listing prints two dates against each policy, a Last Published date and a separate Effective Date, and they are routinely months apart. On 22 August 2026 the entry for "Ablative Treatment for Spinal Pain – Commercial and Individual Exchange Medical Policy" read "Last Published 05.01.2026" above "Effective Date: 02.01.2026." Two different documents. Build a January appeal on the PDF sitting on the site in August and the plan gets to answer that the criteria changed, it will be right, and five weeks of waiting buys you a reply about the wrong text. Print what you find, note the download date, and ask in writing for the version in force on your date of service, identified by its effective date — not the one posted today.

One line on Anthem's library page is worth reading twice: some benefit plans it administers, "such as some self-funded employer plans or governmental plans, may not utilize the Plan's medical policy." So the public library may not be your document at all, and settling whether your plan is self-funded is a short detour worth taking first.

When there is nothing to download

Sometimes the trail runs into a vendor. UnitedHealthcare states it may use tools developed by third parties, "such as the InterQual criteria." Anthem states it is licensed to use MCG guidelines across five sets and may customize them through its Medical Policy & Technology Assessment Committee. Neither library then gives you the text, and both say so: the InterQual criteria are "proprietary to Optum and are not published on this website," and the licensed and customized MCG guidelines "are proprietary to MCG and are not published on the Internet site."

Licensing does not shrink the disclosure duty. It changes the route from download to demand, because the rule reaches the criterion and not the author: where an internal rule, guideline, protocol, or other similar criterion was relied on in a group health plan's determination, the plan must give either the criterion itself or a statement that a copy will be provided free of charge on request (29 CFR 2560.503-1(g)(1)(v)(A)), and the same requirement is repeated for the decision on appeal at (j)(5)(i). If you bought your own policy rather than getting it at work, 45 CFR 147.136(b)(3)(i) puts the issuer under that rule as though it were a group health plan.

Send this to the appeals address on the notice, not the customer service number:

Under 29 CFR 2560.503-1(g)(1)(v)(A) and (h)(2)(iii), and 45 CFR 147.136(b)(2)(ii)(C), please provide free of charge a complete copy of the internal rule, guideline, protocol, or other similar criterion relied on in denying claim [number], in the version in effect on [date of service], including any plan-specific customization of a licensed guideline. Please also provide the explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to my medical circumstances, under (g)(1)(v)(B), and identify any medical expert whose advice was obtained in connection with this determination under (h)(3)(iv), without regard to whether that advice was relied upon.

That last clause is not padding. The identification duty is written to reach advice the plan did not use, which is precisely the advice nobody volunteers. Reviewer notes and internal policy the plan holds regardless of reliance come through a related request; the claim file letter belongs in the same envelope.

The anatomy of a criteria document

Take Aetna's Clinical Policy Bulletin 0016, on invasive procedures for back pain, purely because it is public and you can open it while reading this. Nothing below says whether any of it should apply to anyone. It describes how these files are built.

Scope of Policy. One sentence naming what the bulletin addresses.
Medical Necessity. The load-bearing block, where criteria arrive joined by and. For an initial facet injection, CPB 0016 sets seven conditions in a row: symptoms suggestive of facet joint syndrome; pain confirmed by provocative testing on physical examination; imaging suggesting no other obvious cause; pain limiting daily activities; pain lasting more than three months; pain persisting "despite six or more weeks of conservative treatment (including, systemic medications, and/or physical therapy)"; and radiofrequency facet neurolysis being considered.
Quantity and frequency limits. Same bulletin: no more than three facet joint levels in one session, up to six injections when performed bilaterally.
Exclusions and the experimental list, usually named alongside their codes.
The code table, split into covered and not covered.
Background and References. The evidence the criteria rest on, with publication dates. This is where a policy shows its age.

Watch the conjunctions. CPB 0016 opens by considering "any of the following injections or procedure" medically necessary, a disjunctive list at the top level, then puts a conjunctive list inside each item. Arguing against criteria that never applied to your code wastes a page.

Medicare and Medicare Advantage sit on a different shelf

For Original Medicare the criteria are public by design. The Medicare Coverage Database holds national and local coverage determinations, with report views including Final LCDs by State and Articles by State. The billing and coding articles matter as much as the LCDs, because that is where the code lists live.

Medicare Advantage carries the tightest publication rule on this page. An MA organization may create internal coverage criteria only where criteria are "not fully established" in Medicare statutes, regulations, NCDs, or LCDs, and where it does it must publish the criteria in use, a summary of the evidence considered, a list of the sources, and the rationale for adopting them (42 CFR 422.101(b)(6)). The same section requires the determination to rest on "the enrollee's medical history (for example, diagnoses, conditions, functional status), physician recommendations, and clinical notes" (at (c)(1)(i)(C)). An internal criterion stacked on an existing LCD is the pairing to name first.

Reading the numbered list against the record

The work here is clerical rather than clever. Four columns, one row per numbered criterion.

Criterion, quoted verbatim	What the record says	Where it says it	Gap type

Copy the first column, never paraphrase it. Fill the third with document name, date, and page, in the shape "PT discharge summary, 26 May 2026, p. 2," because a reviewer working a stack checks what is cited and skips what is merely asserted.

The fourth column has only three legal entries.

Not applicable. The criterion addresses a different code, setting, or indication than the one denied. You close it by quoting the scope line against the claim line. Cheapest win available.

Documentation gap. The fact exists but is not in the file the reviewer read, or sits there in a form that does not answer the criterion. A criterion asking for six or more weeks of prior conservative therapy is not answered by a note reading "patient has tried therapy." It is answered by dated records. This is the gap you can close yourself, and closing it is why the exercise is worth doing: you may submit written comments, documents, records, and other information on appeal (29 CFR 2560.503-1(h)(2)(ii)), and the review must take them into account "without regard to whether such information was submitted or considered in the initial benefit determination" (at (h)(2)(iv)).

Clinical gap. The record does not support the criterion because what it describes is not what happened. Not yours to close, and not yours to characterize. Bring the document to the treating clinician and let them answer it in their own letter, or decline to. The regulation assumes the same split: an appeal turning on medical judgment must be decided afresh, without deference to the first decision, by a fiduciary who consults a health care professional with appropriate training and experience in the field of medicine involved, and that professional cannot be the one consulted the first time, or their subordinate (29 CFR 2560.503-1(h)(3)(ii), (iii), and (v)).

While the appeal runs, one protection: if the plan generates new evidence or lands on a new rationale, it must send that to you free of charge, far enough ahead of the final determination to let you respond (45 CFR 147.136(b)(2)(ii)(C)(1) and (2)).

Where the criteria stop governing

A medical policy is not the plan. Anthem says so on the library page itself: coverage decisions are subject to all terms and conditions of the benefit plan, and medical policy "does not constitute plan authorization, nor is it an explanation of benefits." If the plan document covers the service and the policy is the only obstacle, say so plainly. If the plan carries a flat exclusion, meeting every criterion still loses.

The argument that the criteria themselves are out of step with published evidence has one place to land, and it is not the internal appeal. At external review the independent review organization reviews the claim de novo, unbound by conclusions reached inside the plan's process, and its contract must require it to consider — to the extent those documents are available and the IRO considers them appropriate — your medical records, your attending professional's recommendation, appropriate practice guidelines including applicable evidence-based standards, and "any applicable clinical review criteria developed and used by the plan or issuer, unless the criteria are inconsistent with the terms of the plan or coverage or with applicable law" (45 CFR 147.136(d)(2)(iii)(B)(5)). You get ten business days after the eligibility notice to send the IRO more information (at (d)(2)(iii)(B)(2)). Which track you are on now is a separate question: the two tracks are laid out here.

Sentence shapes to reuse, one per criterion

Number your paragraphs to match the policy's numbering. Quote each criterion before answering it. Cite a document and a page for every factual claim. Four shapes cover nearly everything.

For a criterion the record already meets:

Criterion 5 of [policy number, version effective DATE] requires "[verbatim text]." The record satisfies this at [document name], dated [date], page [n], which states "[quote]." That document [was / was not] in the claim file at the time of the initial determination and is enclosed.

For a documentation gap you have now closed:

Criterion 6 requires "[verbatim text]." The determination states this criterion was not met. Enclosed is [document], dated [date], recording [fact] on [specific dates]. Under 29 CFR 2560.503-1(h)(2)(ii) and (h)(2)(iv), this is submitted on appeal and must be taken into account without regard to whether it was considered initially.

For a criterion that does not reach your claim:

Criterion 2 addresses "[scope quote]." The service denied is [code], performed [setting] on [date]. Criterion 2 is therefore not applicable to this claim and cannot support the denial.

For a reason that is not in the document at all:

The determination states "[quote]." The cited policy contains no such requirement in the version effective [date of service]. If a criterion outside this document was relied on, please identify it and provide a copy under 29 CFR 2560.503-1(g)(1)(v)(A) and (j)(5)(i).

And for the criteria that turn on clinical judgment, one line and a handoff: Enclosed is a letter from [clinician], dated [date], addressing criteria 1, 3, and 4. Those are the paragraphs you do not write.

Citations move. If one above has shifted since 22 August 2026, or the document your insurer actually produces reads nothing like the paragraphs here, say so — corrections get made and dated. How these pages are sourced is set out on the about page.