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What to Do When Medicare Denies Coverage

Woman holding up hand to say 'no.'When Medicare declines to cover your medical needs, the denial can leave you with an expensive medical bill. If Medicare refuses to cover your care, do not assume this means you will have to take on the financial burden.

As a beneficiary of Medicare, you have the right to appeal the denial.

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There are many reasons why Medicare might initially fail to cover a type of care, but it is possible to overcome Medicare’s denial by appealing it. Although getting a coverage denial can feel discouraging, those who choose to appeal have a good chance of success. According to Medicare Rights Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals result in coverage for the beneficiary.

Review the Reason for the Denial

After Medicare declines coverage, identify the reason for the denial. Knowing why Medicare claims to be unable to pay for your care can help you appeal successfully.

As a beneficiary of Medicare, you should receive a denial notice if you already received the treatment. The denial notice states the grounds for the rejection. Coverage denials of services you have not yet received will appear on your Medicare Summary Notice.

The most common cause of coverage denials is a subjective determination that the service was unnecessary. Yet as the Alzheimer’s Association explains, there are several reasons Medicare might fail to cover care.

  • A problem with the claim form, such as missing information, errors, or incorrect codes, could result in a denial. When you have a mistake on your claim, it might have been un-processable.

    Contact your provider, who can correct the problem and resubmit the claim. If Medicare has already processed your claim, you may need to submit a redetermination request, which is the first step in the appeals process.
     
  • In other cases, the document may state that the service was “not medically necessary.” For Medicare billing, a procedure or item is medically necessary if it treats an illness, injury, condition, or disease and meets accepted medical standards.

    As an example, Medicare will not cover elective cosmetic surgery because it is unrelated to the beneficiary’s health. Whether health care is “medically necessary” can be a subjective determination. If Medicare denied you coverage because a procedure or item was not “medically necessary,” you can appeal by explaining why you need coverage for your treatment.
     
  • Your denial might note that your claim “does not support the need for this many visits or treatments.” For instance, you could get this notice if you visited your doctor frequently. This decision is a subjective, appealable decision like the determination of medical necessity.

    To appeal, you can explain why your condition required you to make multiple appointments or pursue numerous treatments.
     
  • Sometimes, Medicare denies coverage because of a local rule, making “a local coverage determination.” The notice must refer to the law and state how the beneficiary can get a copy. As unique circumstances can shape the interpretation and applications of local regulations, you can appeal the determination.

Learn more about how to appeal a Medicare denial. For assistance appealing, reach out to an elder law attorney in your area.


Created date: 05/27/2008
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