How To Appeal Medicare Denials

It’s easy to throw up your hands and say, “Okay,” when a Medicare insurer denies coverage for a medication your doctor has prescribed, a visit to a specialist, or a treatment regimen. We get it. We’ve been there. We don’t like to give up.

You deserve the coverage and if you appeal you have a really good chance of winning. The process is a lot easier than you think. More than 60 percent of those who do appeal get what they want, according to Joe Baker, President of the Medicare Rights Center.

In our short video Baker explains what you need to do when you appeal. Here are a few essentials:

The law gives you the right to appeal denials for:

  • Prescription drugs
  • Health care services
  • Health care supplies you need

You can appeal if you’re denied approval, or if Medicare or the insurer stops paying while you’re using the medication or getting the health care service.

Where to start

  • If you’re denied, ask your doctor for help. A physician’s participation in the appeal is extremely important.
  • Call your plan. A lot of denials are overturned after you call and ask for reconsideration.

If a phone call doesn’t work

Every time you’re denied you receive an instruction notice about appealing.

Follow the instructions on the notice and attach documentation from your doctor. A letter explaining why you need the treatment or medication often does the trick.

Medicare Advantage and Medicare Plan Appeals

If you have Medicare Advantage or another Medicare plan, the insurer can take up to 14 days to decide your case. But you can ask for a speedier response.

Your letter, or email, from the doctor must say your health will be harmed if you wait for the 14 days. The insurer is required to respond within 72 hours.

Prescription Drugs

If your insurer denies a particular medication, the pharmacist can’t tell you why. The Medicare Rights Center is advocating to change this policy, but for now you need to consult your doctor about other options.

He or she may prescribe a generic drug. If a generic medication is unsuitable, ask your doctor to write an appeals letter, or email, explaining why you need the brand-name medication.

If the drug isn’t included in the insurer’s list of covered drugs, or formulary, you and your doctor can ask for an exception for you. The request must include an explanation of why you need the medication and why your health or life will be jeopardized without it.

Similarly, if the medication is too expensive you might be able to get the insurer to agree to a lower payment. But again, the doctor has to offer a compelling explanation about why you need the medication.

If the insurer continues to deny coverage

It probably won’t get that far. But there are five levels of appeal.

1. Review by Medicare or the insurer.

2. Review by what Medicare calls an Independent Review Entity.

3. Review by an administrative law judge.

4. Review by the Medicare Appeals Council.

5. Review by a federal district court judge.

Don’t be put off by this long list. In most cases, you don’t have to go through all the hassle.

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Barbara Nevins Taylor

As the winner of 22 Emmy Awards and a slew of journalism honors and awards, I created ConsumerMojo.com to give you the straight story about complicated stuff. Tell us what you want to know and we'll get you the answers.