Can I appeal against a Medicare decision?

Medicare covers medical services and procedures that are medically necessary. While some services and procedures don’t require much explanation of medical necessity, others need multiple codes and documentation proving the medical necessity of the service or procedure. Based on the information provided to Medicare by the doctor, Medicare will then approve or deny coverage.

If Medicare denies a claim or a part of a claim, the Medicare beneficiary has the right to appeal against the decision. However, beneficiaries may need to provide several documents as well as an appeal letter to state their case. Also, the process of a Medicare appeal can vary based on the type of coverage.

How to appeal a Medicare Part A or Part B decision

Medicare can deny a claim for several reasons. Sometimes getting the decision reversed is as easy as having the doctor change the code on the claim and resubmit the claim to Medicare. However, other times, the only logical next step is to file an appeal of Medicare’s decision.

For example, a beneficiary is given a prescription from his doctor for a wheelchair. The beneficiary goes to a Medicare-approved durable medical equipment supplier and fills his prescription. However, Medicare says the wheelchair is not medically necessary in this situation, so the beneficiary must pay for the wheelchair on his own.

Medicare can only base its decisions on the information provided. If the information provided doesn’t justify coverage, Medicare will deny the claim. The good news is the beneficiary can file an appeal against Medicare’s decision with the help of his doctor to see if Medicare will reverse its decision.

Steps to filing an appeal against Part A or Part B

The beneficiary must file his appeal within four months of receiving the denial of the claim, called the Medicare Summary Notice.

To submit an appeal against Original Medicare (Part A and Part B), beneficiaries need to:

Fill out a Medicare Redetermination Request Form.
Circle the item or items on the Medicare Summary Notice that they are appealing.
Write an appeal letter that clearly explains why they think Medicare should cover the item or items.
Submit the letters and form to the address listed under the appeals section of the Medicare Summary Notice.

Beneficiaries should also include any relevant documents and notes from their doctor’s office that could support the appeal.

If the appeal is denied, the beneficiary has the option to appeal at a second level with a Qualified Independent Contractor. If the appeal is still denied, beneficiaries will have the option to appeal at three other levels, all the way up to a judicial review by a federal district court.

How to appeal a Medicare Part C decision

Appealing a decision made by a Part C plan, also called a Medicare Advantage plan, is similar to appealing an Original Medicare decision. However, because Medicare Advantage plans are run by private insurance carriers, the process can vary from plan to plan.

For example, a beneficiary is sent to a skilled nursing facility after a hospital stay to continue his recovery. However, while there, he is too weak to start physical therapy, so his recovery team prolongs his start date for therapy. His Medicare Advantage plan just sees that he isn’t participating in physical therapy, and therefore, declines coverage for the skilled nursing facility stay.

However, because the beneficiary is physically unable to participate in therapy and plans to start at a later date, he has grounds to file an appeal against his plan’s decision. Generally, the beneficiary will need to:

Put together a timeline of events using his Explanation of Benefits.
Compile all doctor’s notes and records as well as the denial letter.
Write an appeal letter.

Try to keep a professional, neutral tone in the appeal letter. Emotions can make it more difficult to get a favorable decision.

Other types of appeals

Medicare beneficiaries can also appeal things such Part D decisions, late penalties, and more. Many of the forms needed for filing an appeal can be found on Medicare’s website. If a beneficiary needs to file an appeal through an insurance carrier for their Medicare Advantage plan or Part D plan, he should contact the plan carrier to get detailed instructions on how to initiate the appeals process.

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.