The Process of Appealing a Medicare Decision

Medicare is the primary insurer for most seniors, and for the most part, people are very satisfied with their Medicare coverage. Sometimes, however, Medicare gets it wrong—they deny a service you’re pretty sure they should cover.

It’s frustrating when you think Medicare made a mistake, but you’re not without options. You have the right to appeal any decision made by Medicare, Medicare Advantage, or your Medicare Part D Prescription Drug Plan.

What Medicare decisions can I appeal?

Technically, any coverage decision made by Medicare or your Medicare Advantage or Part D plan can be appealed, whether they happen before or after a service is received. For example:

• You visit the doctor for a routine wellness check and he decides to run some blood tests. Medicare pays for the doctor’s visit but denies the blood work because they didn’t think it was medically necessary.
• Your doctor orders a lift chair but Medicare won’t authorize payment for the device.
• You visit an urgent care center while you’re traveling and your Medicare Advantage HMO denies payment because the provider isn’t in the plan’s network.
• Your Part D plan won’t pay for a more expensive brand-name medication even though your doctor believes the generic medications won’t be effective for your condition.

How do I appeal a decision by Original Medicare?

You have 120 days after you receive your Medicare Summary Notice to file your initial appeal. You can either download and print the Medicare Redetermination Form or write your appeal on a piece of paper.

Explain clearly why you believe Medicare should pay for the item or service. Ask your doctor to write a letter to support your appeal. Include any additional information you think might help Medicare better understand the situation.

If you don’t use the Medicare Redetermination Form, make sure you include your name, Medicare ID number, and phone number on your written response. Mail your paperwork to the address at the bottom of your Medicare Summary Notice—and remember to make copies of everything for your files.

If Medicare doesn’t reverse its decision, you can request a “reconsideration,” which is the second level of appeals. The instructions for filing are included in the notice you receive from Medicare.

You can escalate your appeal to an Administrative Law Judge and even federal court if the disputed amount is above a certain level. Instructions for escalating to the next stage are included on your notice from Medicare.

How do I appeal a decision by my Medicare Advantage plan?

Even though Medicare Advantage plans are administered by private insurance companies, you don’t lose any Medicare rights, including the right to appeal a coverage decision.

Most plans allow you to initiate an appeal online from your member account. If you don’t have an online account, contact the member services department. They will be able to help you file an appeal.

If your plan doesn’t decide in your favor, you have the right to request an independent review. From there, you can also escalate to an Administrative Law Judge and the federal courts if the disputed amount is high enough.

How do I appeal a decision made by my Part D prescription drug plan?

Part D plans are administered by private insurers, so you should consult your plan booklet or online account to see how to handle complaints about your drug coverage.

If your doctor orders a prescription that isn’t on your plan formulary, or list of covered medications, your doctor can call the plan and request an exception, as long as you haven’t already filled the prescription.

Once you buy the medication, you need to file your request in writing. If it’s approved, you’ll be reimbursed for the covered portion.

Part D plans have seven days to respond to a request for an exception. However, if your doctor believes your life is at risk if you don’t get the medication, he can request an expedited decision.

If your plan doesn’t approve the exception, it will notify you in writing. Instructions for escalating your appeal to the next step will be included with your notice.

Where can I get help filing an appeal?

Your State Health Insurance Assistance Program (SHIP) is a great resource for help with Medicare issues. Although you aren’t required to hire a lawyer to file a Medicare appeal, you may want to get professional advice, especially if the amount of the claim is significant.

Danielle K. Roberts is a Medicare insurance expert and co-founder at Boomer Benefits, where her team of experts help baby boomers with their Medicare decisions nationwide.