How To Appeal a Medicare Decision in Easy Steps

Whether it’s a permanent late penalty on Medicare premiums or Medicare did not cover a service or equipment you believe should be covered, you have the right to appeal the decision. The steps are a little different, if you have Medicare Advantage (MA) or Prescription Drug Plan (Plan D) but all original Medicare, Medicare Advantage (Part C) and Prescription Drug plans have five levels of appeal, meaning you can continue to appeal up to five times if you’re continually denied coverage on a claim or the prior acceptance of a service, drug or equipment. See how to proceed with an appeal below.

On This Page

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  Common Reasons People Appeal Medicare Decisions

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  Filing a Medicare Advantage Appeal

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  The 5 Levels of Filing a Medicare Appeal

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  What Is a Local Coverage Determination (LCD)and How Do I File a Challenge?

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  Can I have someone else file an appeal for me?

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  How To Appeal Medicare FAQs

Common Reasons People Appeal Medicare Decisions

1. Medicare won’t cover or reimburse you for a service that you believe is medically necessary. Having medical professionals write a letter on your behalf greatly increases your chances of getting Medicare to reverse their denial of coverage.

2. Medicare won’t cover or reimburse you for the equipment you need for optimal health. Again, a doctor’s note explaining why it’s medically necessary will help.

3. Medicare requires you to pay a large share of the services, drugs or equipment that you need. You may need to prove that the services or items are medically necessary, preferably with a doctor’s note, as well as proving that you are financially unable to pay your share. Also, check to see if you qualify for Medicaid in addition to Medicare, if you are low-income.

4. Medicare stops covering a service, treatment or prescription drug you still need. As with most appeals, proving that you still need what Medicare is discontinuing coverage for is more effective with a doctor’s note explaining why it’s still medically necessary.

5. You meet the Overutilization Monitoring System criteria, which means you’re exceeding limits placed on addictive medications, like opioids and benzodiazepines, which are often abused. You may have a better chance of getting an extension if your doctor is willing to write a letter explaining the extended time you’re taking these types of medications.

Filing a Medicare Advantage Appeal

Most Medicare Advantage (MA) insurers are explicit about what they cover and do not cover and even have drug formularies and a list of equipment that show what they will pay for what they won’t.

Even though MA is held to the same standards as original Medicare, because plans are privately held with different groups, it’s important that you reach out to your plan and ask how you can begin the appeal process if you receive a letter of denial. Mailing addresses will differ from original Medicare plan addresses.

MA plans are required to give you detailed information about how to proceed with your appeal, in writing. You can also find this information on your plan membership card.

When writing your appeal, your best chance of success is by enlisting the help of your doctors. A doctor can even write a letter requesting expedited redetermination.

Redetermination may take 30 to 60 days. Just as with original Medicare, there are five levels of appeals, with a chance to overturn a denial. See below in the next section, as the steps are exactly the same. ^[3]

The 5 Levels of Filing a Medicare Appeal

You will receive a Medicare Summary Notice (MSN) with an initial denial. This is important because it tells you how long you have to file an appeal. If you miss this date with good reason, you may appeal by showing why you missed the deadline. When possible, arrange an extension beforehand with a solid reason for the delay.

There are five levels of appeals, so an initial denial is not the end of the story. After receiving an initial denial, the Medicare recipient will receive a statement of denial, which will contain a Medicare Summary Notice (MSN) along with steps on how to proceed to the next level appeal.

If level one doesn’t result in an overturn of the denial, another MSN will be sent about how to proceed to level two, which allows a new set of eyes to redetermine the case. If that fails, there will be an MSN sent with steps on how to proceed to level three and so on. ^[1]

With each level of redetermination, the Medicare recipient will be sent detailed instructions on how to proceed. The final step is federal court, and it may take months or over a year to reach that level. Here are the 5 levels, in order:

1. Redetermination

2. Qualified Independent Contractor (QIC) Reconsideration

3. Decision by the Office of Medicare Hearings and Appeals

4. Review by the Medicare Appeals Council

5. Judicial Review in Federal District Court

What Is a Local Coverage Determination (LCD)and How Do I File a Challenge?

An LCD is original Medicare, just on a local level. A Medicare Administrative Contractor (MAC) is someone who makes local decisions about coverage for a specific service or equipment or drug coverage in the Medicare recipient’s region, in accordance with the Social Security Act. LCDs are decisions made by MACs. ^[2]

A recipient can appeal an LCD that denies them a service, drug or equipment due to location, if they have both Part A and Part B Medicare and what they need is not covered by a particular LCD.

When To File an LCD Appeal

Before getting the service or item, you must appeal an LCD six months prior, with a written statement from a physician that you require the service or item.

If you’ve already gotten the service or item, you have 120 days to appeal an LCD that results in a denial.

Where To File an LCD Challenge

When you challenge an LCD, it’s important to include as much personal information that is relevant to the challenge, like residential address, email address, phone number, health insurance claim number, the assigned MAC and the title of the LCD you’re challenging, along with a doctor’s attestation that the particular item or service that you want is necessary. Also, write a detailed explanation as to why you think the LCD is wrong. Mail these documents to:

Department of Health & Human Services

Departmental Appeals Board, MS 6132

Civil Remedies Division

330 Independence Ave., S.W.

Cohen Building, Room G-644

Washington, DC 20201 ^[3]

Can I have someone else file an appeal for me?

You can appoint someone (family member, attorney) as a representative to help file the Medicare appeal. You will need to fill out an"Appointment of Representative" form from Medicare or write a statement appointing them as your representative. In the statement of appointment, you must provide:

• Medicare ID #

• Address/phone number

• Information about who the representative is

• Where the representative lives

• The representative’s relationship to you

• The representative’s phone number

• The representative’s professional status.

You’ll also need to expressly authorize the release of personal and health information to the representative. It’s important to explain why you’re being represented and to what extent.

You will need a signed affidavit from the representative if challenging an LCD in writing. ^[1]