How do I appeal a decision by Medicare or my plan if they deny coverage for a procedure or medication I need?
Answered by 12 licensed agents
To appeal a decision by original Medicare, contact Medicare. If your Part D plan is denying prescription drug coverage, have will need to request that your doctor file for a "formulary exception" with your insurance. If the insurance company decision is to deny the requested exception, you need to feel an appeal with your insurance. The recommended plan of action for an insurance company's denial of coverage for a specific procedure is you need to contact your insurance company and file an appeal of the denial. Your independent Medicare health insurance agent (who sold you the plan) most assuredly should be able to help you.
Under traditional Medicare, you will appeal directly to Medicare, and Medicare supplemental/Medigap coverage must follow Medicare's lead in paying your coverage cost. With Medicare Advantage, you will deal directly with the insurance companies that write those plans.
You call the plan directly and file an appeal. The number will be on the back of your card. Also, if this is a drug plan, you can request a formulary exception if all other options have been exhausted.
Believe it or not, you have 4 appeals as a member of the Medicare system. The pattern is that you will be declined on your 1st appeal. But on the 2nd one, now they know that you mean business. Once the appeals has been exhausted, you can now file a grievance thru the Medicare website.
Please visit the Medicare link listed below for all the details including forms. I would call your agent for assistance. if you don't have an agent, you could call Medicare.
There are different ways to appeal a decision based on what type of Medicare coverage you have, whether that's Original Medicare, or a Medicare Advantage Plan. If you have a good Independent Broker, they should help you appeal any decision that you don't agree with.
You can contact your insurance agent to help you file an appeal if you like. If you don't have an agent, you can contact customer service on your health plan and they can help you with the appeal process.
You can file an appeal if your plan denies a request. You can also appeal if your plan stops paying or providing for all or part of a healthcare service, supply, item, or prescription drug you think you still need. Make sure your evidence of coverage has the correct information about your claim. Ask your doctor, healthcare provider, or supplier for any information that may help your case. For details about your appeals rights, see your evidence of coverage or contact your insurer.
If Medicare or your plan says “no” to paying for a procedure or medicine you need, don’t worry — you can ask them to take another look. This is called an appeal you can politely ask them to review it again.
Here’s how you can appeal, step-by-step:
1. Look at Your Denial Notice:
Medicare or your plan will send you a letter that says they won’t pay. It’s called a "Notice of Denial." Keep this paper — it explains why they said no and tells you how to start an appeal.
2. Ask for a Redetermination (First Appeal):
You’ll need to fill out a simple form or write a letter saying you disagree and why you think they should cover it. Send it to the address listed on your denial notice.
Tip: It’s smart to have your doctor write a note too, explaining why you really need the treatment or medicine.
3. Follow the Deadlines:
You usually have 120 days (about 4 months) from the day you got the denial to file your appeal. So don’t wait too long!
4. What Happens Next:
After you send your appeal, Medicare or your plan has to look at it again and give you an answer. If they still say no, you can keep appealing at higher levels if you want.
Important: Always keep copies of everything you send or get — like letters, forms, and doctor notes — just in case you need them later!
If at first you don't succeed, try try again.... or file an appeal. If you have a Medicare Part C or Part D plan and something isn't covered or you disagree with a decision, you will file the appeal directly with your insurance carrier. You will get an official letter with steps that must be followed to file an appeal. If that appeal doesn't satisfy you then you can continue to appeal several more times. It's like taking a case all the way to the Supreme Court in a sense. If you were denied directly from Medicare itself then you have to file the instructions on the Summary Notice to appeal. It's a very good idea to always make sure that you support your appeal with any important information that should be known. If your doctor or health care provider can assist with this information, get it! Don't get discouraged and make sure you stand up for yourself. The Medicare appeal system is often underutilized and many people take that initial denial as the final decision. It's not! Fight on!
It is best to have your medical provider initiate the appeal because they will have to demonstrate the medical need for the service. Many appeals are granted once the medical need is established but certain procedures, like cosmetic or experimental treatments will often be denied.
