Appealing to Medicare if You Are Denied      

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Many Medicare recipients have found themselves in situations where their physician feels they need a particular procedure but Medicare won’t approve it.  Most people don’t know what to do when they find themselves in this situation.

The Medicare Rights Center, which is a national nonprofit organization, says 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 it comes down to whether Medicare agrees 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 happens quite a lot 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 and you end up being denied. 

The Medicare Rights Center also says that many people don’t realize that they can appeal, or they think that the appeal process is too difficult.  In actuality, the process is not that difficult and everyone has the right to appeal. 

Some things that an individual should do to have a successful appeal as suggested by the Medicare Right Center are:
• 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 the review and explaining why it should have been covered;
• Have the doctor include a letter explaining why the suggested procedure should be medically necessary and approved;
• Save photocopies of all written and oral communication, including notes, names and dates of ;hone calls;
• Make sure to do all of these things well within the 120 days allowed, or it will be too late to appeal;
• If you are in a private plan such as an HMO or PPO remember that you only have 60 days to appeal and some of the steps may be different.

It can be frustrating to get a denial, however, hopefully this information will help you if you ever find yourself in this situation.  Hopefully, this will not happen, but if it does, this information should help you get the care you need.

Entry Filed under: General-Medicare