You open the mail, and your stomach drops. The Medicare Summary Notice shows a service or item as “Denied.” It’s infuriating and, additionally, very scary. Many people simply give up and pay the bill. However, a denial is *not* the end of the road. You have the right to appeal, and a surprising number of appeals are successful.
First, understand “Why” You Were Denied
Before you can fight, you need to know the battlefield. Look closely at your denial notice. It must state the specific reason for the denial. Sometimes, it’s a simple coding error from your doctor’s office. Other times, Medicare deems the service “not medically necessary.” This reason will guide your entire appeal.
Level 1: Redetermination (The First Appeal)
This is your first official appeal. You must file this request within 120 days of the denial. You simply need to circle the denied item on your Summary Notice, write “Please appeal,” and send it in. However, a stronger approach is better. Therefore, you should also include a letter of support from your doctor explaining why the service was necessary.
Level 2: Reconsideration (The Second Look)
If your Redetermination is also denied, you move to Level 2. You have 180 days to file for a Reconsideration. This time, however, your case is sent to a Qualified Independent Contractor (QIC). This is a fresh set of eyes. Consequently, you must submit *all* supporting evidence now. Include medical records, doctor’s letters, and any relevant studies.
Levels 3-5: The Higher Courts (ALJ, MAC, and Federal)
If the QIC denies your claim, don’t despair. You can escalate further, but now it involves real hearings. Level 3 is a hearing with an Administrative Law Judge (ALJ). Many patient advocates find great success at this level. After that, you can go to the Medicare Appeals Council (Level 4) and, finally, Federal District Court (Level 5).
Keys to Success: Documentation is Everything
A successful appeal boils down to one word: evidence. You cannot simply say you need something. You must “prove” it. Get a detailed letter from your doctor. This letter should explicitly state why the treatment is medically necessary for you. Furthermore, it should cite your medical history. Keep copies of everything.
Don’t Take “No” for an Answer
The Medicare appeals system is complex. It’s designed to be confusing. However, persistence pays off. Many people win their appeals at Level 2 or 3. You paid into this system. Therefore, you must be your own best advocate and fight for the coverage you are entitled to.
Fighting insurance denials is incredibly frustrating. What’s the most confusing or unfair denial you’ve ever had to fight for yourself or a parent?
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The post How to Appeal a Medicare Denial (And Win): A Step-by-Step Guide appeared first on Budget and the Bees.
