Appeal if You Are Denied Services

Many Medicare recipients have found themselves in situations where their physician feels they need a particular procedure but Medicare won’t approve it.  When this happens, most people don’t know what to do.

There is a national nonprofit organization called the Medicare Rights Center. They advise that the best thing to do in this situation is to appeal the decision.  Medicare is supposed to approve any medically necessary procedures, however, quite often Medicare doesn’t agree with the doctor’s idea of what is medically necessary.

According to the Medicare Rights Center, it is often easy to win appeals for a number of reasons.  One thing that often happens is that the denial is based on an accidental coding error, which means that someone put the wrong number or letter into a computer, making the computer think that you are requesting something different than you actually are requesting, and you end up being denied. 

The Medicare Rights Center also says that many people don’t know that they have the right to appeal, or they think that the appeal process is too difficult.  Everyone has the right to appeal and the process is not too difficult.   

To have a successful appeal the Medicare Rights Center suggests:
• Sign the back of the Medicare Summary Notice (MSN) and write on the front of it “Please Review”- send it back to the correct address by certified mail or with delivery confirmation;
• Include a letter with the MSN asking for an appeal and explaining why it should have been covered;
• Have the doctor write a letter explaining why the procedure is medically necessary and why it should be approved;
• Make photocopies of all written and oral communication, including notes, names and dates of phone calls;
• Do all of these things well within the 120 days allowed, so it does not end up too late to appeal;
• If you are in a private plan such as an HMO or PPO you only have 60 days to appeal and some of the steps may be different.

It can be frustrating to get a denial.  This information can be helpful if you ever find yourself in this situation.  Hopefully, this will not happen to you, but if it does, following these guidelines can assist you in obtaining a successful appeal.

Filed under: General-Medicare

Tags: denial of services, General-Medicare, medically necessary, Medicare Appeal, Medicare Rights Center