What if Medicare will not pay for something?

You can appeal if:

• Medicare refuses to pay for a health care service, supply, or prescription that you think you should be able to get.
• Medicare refuses to pay the bill for health care services or supplies or a prescription drug you already got.
• Medicare refuses to pay the amount you must pay for a drug.
• Medicare stops paying for all or part of a service you think you still need.

Take action right away. You must appeal by the deadline. All appeals have deadlines. Different kinds of appeals have different deadlines. Your denial notice should tell you how much time you have to appeal.

Note: If you need help with an appeal, call the Medicare Advocacy Project at 1-800-323-3205 to apply for assistance.

Remember:

1. Appeal on time,
2. Keep copies of all your paperwork, and
3. Try to get your doctor’s support.

It is very important to get your doctor to support your appeal. Ask your doctor for a letter that explains the medical reasons you need the service Medicare is denying.

How you appeal depends on what part of Medicare you are appealing: original A or B, Part C, or a Part D plan. You may appeal each of these plans through several administrative steps.

If you are appealing a Part C or Part D decision, contact your plan for instructions on how to appeal.

If you have Part B Original Medicare, you should get a statement every 3 months. The statement is called a Medicare Summary Notice (MSN). It shows the services that were billed to Medicare. It also shows you if Medicare will pay for these services. At the bottom of the MSN, there are instructions on how and when to appeal.

If you need a particular medication and your drug company says it is not on their covered drug list, ask your doctor to file for an “exception.” Your doctor must explain that no other drug on the list is as effective as the drug you need, or the other drugs on the list will cause negative side effects.

If Medicare approves the exception, generally the approval lasts until the end of that plan year. If Medicare does not approve the exception, you can appeal to a higher level and try to get another decision.

If you appeal, Medicare will send you their decision. 

• They may “change or reverse the denial.” This means that they decide to pay some or all of the charge. 
  or
• They may still deny your claim. The letter will include instructions for how to file the next step of the appeal.

If Medicare still denies your claim after you appeal, you can appeal to:

1. an Administrative Law Judge, then to 
2. the Medicare Appeals Council, then to 
3. Federal Court.