Medicare Appeals: What Decisions Can You Appeal?

What Medicare decisions are appealable?

A Medicare appeal is used when you disagree with a decision about whether Medicare or your plan will cover or pay for something. Depending on your coverage, you may be able to appeal decisions involving:

• A service, supply, item, or prescription drug that Medicare or your plan says is not covered.
• A request for payment that Medicare or your plan denies.
• A decision to pay less than you believe Medicare or the plan should pay.
• A decision to stop providing or paying for all or part of care you believe you still need.
• Certain Medicare drug plan decisions, including coverage determinations and some drug management program decisions.

Can you appeal Original Medicare decisions?

Yes. In Original Medicare, appeal rights usually begin after Medicare makes a coverage or payment decision on a claim. The decision is listed on your Medicare Summary Notice, often called an MSN.

You can appeal items or services listed on the MSN if you believe Medicare should have covered them or paid more. Medicare.gov says you must file by the deadline shown on the MSN, although you may still be able to file late if you can show good cause.

Can you appeal Medicare Advantage plan decisions?

Yes. In a Medicare Advantage Plan, coverage decisions are called organization determinations. These decisions can address whether a service, drug, or supply is covered and what the plan will pay.

If the plan gives an unfavorable initial decision, you or your representative can usually ask the plan to reconsider. Medicare.gov refers to this first level of appeal as a Health Plan Reconsideration. The plan’s written decision should explain how to appeal and the deadline for doing so.

Can you appeal Medicare drug plan decisions?

Yes. In a Medicare drug plan, an initial drug coverage decision is called a coverage determination. If you disagree with that decision, you, your representative, or your prescriber can ask for a redetermination.

Examples may include a plan refusing to cover a drug, denying an exception request, deciding that prior authorization or another utilization management rule has not been met, or denying payment for a covered drug. If an exception is requested, the prescriber generally must explain the medical reason for the exception.

Can you appeal if Medicare-covered care is ending too soon?

Yes, in certain situations you may have the right to a fast appeal if you believe Medicare-covered services are ending too soon. This can apply to settings such as a hospital, skilled nursing facility, home health agency, hospice, or comprehensive outpatient rehabilitation facility, depending on the notice you receive and your coverage.

Fast appeal rules are time-sensitive. The notice you receive should explain who to contact and by when. If you continue services after the coverage end date, you may be responsible for costs unless the appeal decision is in your favor.

What is not handled as a Medicare appeal?

Not every Medicare problem is an appeal. If your concern is about the quality of care, customer service, waiting times, disrespectful treatment, or another service problem, Medicare generally treats that as a complaint or grievance, not a coverage appeal.

Also, an Advance Beneficiary Notice, or ABN, is not by itself an official Medicare denial. If a claim is later submitted and Medicare denies payment, that denial may give you appeal rights.

Official Sources