Can I Appeal to Medicare about what is Medically Necessary?
Summary: Medicare only pays for medically necessary care. If you have a service denied, you can appeal that it is medically necessary.
Medicare will generally pay for services that are considered medically necessary. The Centers for Medicare & Medicaid Services (CMS) decides what is medically necessary based on the medical community’s accepted standards of care. You have the right to appeal the decision if your plan denies coverage. Appeal means to apply for a different decision.
How does a Medicare plan decide what is medically necessary?
Usually, the plan consults with licensed doctors, pharmacists, and other health professionals in making its decisions about medically necessary care. You have the right to appeal your plan’s decision not to cover a service, prescription, or supply.
Under what circumstances can I appeal an unfavorable decision about medically necessary services or supplies?
Your right to appeal what is medically necessary applies to all types of Medicare plans. You have the right to appeal an unfavorable decision whether you receive your coverage from
- The government-administered Medicare program,
- A Medicare Advantage plan offered by a Medicare-approved private insurance company, or
- A Medicare contracted private company that administers your Medicare Part D Prescription Drug Plan.
Some situations in which you can appeal your plan’s unfavorable decision about medically necessary services or supplies include:
- A request made for a healthcare service, supply, or prescription drug in advance. For example, a request for an overnight stay in the hospital for a procedure that is normally done outpatient at the hospital.
- Supplies, services or prescriptions that you have already received. For example, you may have visited the doctor for treatment of an injury. During the visit, the doctor performs an EKG test. Your plan receives the claim and determines the EKG was not medically necessary and denies payment for the test.
- Inpatient hospital care is no longer considered medically necessary.
- Medication is not on the plan’s formulary (list of covered drugs)—even if prescribed by your doctor.
How do I file an appeal?
You, your doctor, or your authorized representative may file an appeal.
Usually you must appeal within 120 days of receiving the plan’s decision that the care is not medically necessary.
If you are appealing a decision about medically necessary services you already received, you may be required to put your appeal in writing.
You may likely need your doctor’s help to prove that your care is medically necessary. You will need to provide the portions of your medical record that apply to your appeal and a doctor’s statement that the service, supply, or medicine was medically necessary.
More information on how to appeal is on your Medicare Statement of Non-Coverage (MSN). You can also get help with an appeal from your State Health Insurance Assistance Program (SHIP).
What can I expect when I file an appeal?
Your plan will review your appeal and any supporting documentation you send. Because the original denial was based on a decision that the care was not medically necessary, a physician or other appropriately licensed clinician will review the appeal and make a decision either to overturn or to support the original coverage denial. You will be notified of the decision in writing.
If you aren’t satisfied with this decision, you can ask for a “reconsideration” by an independent review organization (IRO). If the IRO disagrees with the first review decision, the plan will pay its portion for the care to comply with the IRO’s decision. The IRO will notify you and the plan of its decision.
You may have the right to file an appeal to an Administrative Law Judge if you don’t agree with the IRO’ decision. The cost of the care in dispute must meet or exceeds a defined amount (i.e., amount in controversy) to appeal at this level. If you disagree with the Administrative Law Judge decision, you may appeal to the Medicare Appeals Council, and finally to a federal court.
Other places to learn more about your appeals rights:
- Your Medicare and You handbook,
- Your Evidence of Coverage,
- Your Medicare plan,
- gov on the internet, or
- Call 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048.
You can find Medicare plans of various types where you live by entering your zip code and clicking the Browse Plans button on this page.