How to Appeal When Medicare Refuses Coverage

When Medicare denies you coverage of a health care service, supply, item, or drug or changes the cost of care, you can appeal. If you receive a coverage rejection, get guidance from an elder law attorney and start the process right away.

As the United States Department of Health and Human Services explains, there are five levels to the appeal process, and your appeal could go to federal court if the value of the care meets a minimum threshold. In 2023, the medical care’s value must be at least $1,850.

Notifications of Coverage Denials

If Medicare has refused to cover care you already received, you should get a denial notice explaining the reason for the turndown. The quarterly Medicare Summary Notice (MSN) for traditional Medicare and the monthly Explanation of Benefits for Medicare Advantage can alert you to a denial in advance.

Read more about the reasons why Medicare denies coverage.

Appeal Process

Before appealing, review the denial notice, Medicare Summary Notice, or Explanation of Benefits and notify your health care provider. Medicare.gov recommends requesting information that helps your case from a doctor, health care provider, or supplier.

Your physician can also act as your spokesperson and appeal on your behalf, or you can appeal yourself. An attorney can represent you in your appeal, lending an understanding of the system’s complexities and ensuring you meet critical deadlines.

Identify the Appeal Deadline

It is crucial to be aware of your appeal deadline. Traditional Medicare beneficiaries can find the date on the MSN. Those with a Medicare health plan like Medicare Advantage can review the plan’s initial denial notice and materials for the deadline. Generally, you have 60 days following the coverage determination to ask for a reconsideration.

Although your case will be more straightforward if you meet the deadline, you can still appeal if you miss the deadline by showing “good cause.” For example, if you missed the deadline because you or a loved one were in the hospital or your MSN went to the wrong address, you may have reasonable cause for a late appeal.

The first level of the appeals process requires you or your representative to fill out the Redetermination Request Form. You then submit it to the Medicare Contractor for traditional Medicare or the Medicare Advantage Plan. Generally, decisions can take up to two months.

If the Medicare Contractor or Medicare Advantage Plan denies your appeal, you can appeal to the next level: review by a Qualified Independent Contractor or an Independent Review Entity. After that, the case can escalate to the Office of Medicare Hearings and Appeals, then to the Medicare Appeals Council, before reaching federal court.

Expedited Decisions

Those who show that waiting for a decision would seriously harm them can get a fast decision within 72 hours. For instance, if your health would severely decline without access to a medication or treatment, you could request an expedited appeal. Your doctor can reach out to your plan and certify that you need a decision soon.

How Your Attorney and Doctor Can Help

As with an expedited appeal, your physician can play an essential role in the appeal process, lending credibility to your claim. Having your health care professional on your side can strengthen your case.

In addition to your doctor, an attorney can help you navigate the appeal process, keeping track of deadlines and ensuring you file your appeal correctly. An attorney can represent you in federal court if your case progresses to the final stage of the appeals process. Find a qualified attorney near you.