Brenda Lyle – Florida Today
By Brenda Lyle
Q: Medicare denied my claim –what can I do?
A: Receiving a denial from Medicare or your Medicare Advantage plan can seem like a defeat—especially for treatment or medication your doctor believes you need. It may feel like David versus Goliath, but you have the legal right to appeal. In Original Medicare, fewer than 12% of beneficiaries ever appeal. But for those who do, approximately 50% of first-level appeals are successful. And chances for success increase at each subsequent stage of the appeals process. The same goes for Medicare Advantage members, with roughly 82% of appeals succeeding! Understanding the process is step one.
Why Was Coverage Denied?
Before starting an appeal, learn exactly why your claim was denied. The “Notice of Denial of Medical Coverage” document or “Medicare Summary Notice” (MSN) is your roadmap. These documents will explain the reason for the denial, with important codes related to your claim.
Common reasons include a determination of “not medically necessary,” insufficient documentation from your provider, or use of an out-of-network doctor (particularly in HMO-style Medicare Advant
age plans). Was treatment approved by your primary care physician? Your appeal must address the specific reason for denial.
Five Levels of Appeal
The Medicare appeals process follows a structured, five-step path. Each level must be completed before moving to the next:
- Redetermination: Request that Medicare or your plan review the claim again.
- Reconsideration: An independent organization reviews your case.
- Administrative Law Judge Hearing: You present your case, typically by phone or video.
- Medicare Appeals Council: A higher-level review of the judge’s decision.
- Federal District Court: The final step, usually reserved for high-dollar claims.
Original Medicare vs. Medicare Advantage
While the appeal levels are similar, deadlines and procedures differ. With Original Medicare, you typically have 120 days from the date on your MSN to file your first appeal using Form CMS-20027. Medicare Advantage plans, run by private insurers, usually require appeals within 60 days.
Building a Strong Case
An appeal is more than a complaint—it’s an evidence-based argument. Ask your doctor for a “Letter of Medical Necessity,” explaining why the treatment is essential for you and why alternatives are not appropriate. Strengthen your case with medical records, second opinions–even peer-reviewed research. Thorough documentation increases your chances for success.
Organization is Key
Keep a log of conversations– with dates, times, and representative names. Always send appeal documents via trackable certified mail. And DON’T miss deadlines—even a one-day delay can mean dismissal.
For residents of Brevard, Seminole, Orange, Osceola and Lake Counties, free, unbiased help with your appeal is available through Florida SHINE (Serving Health Insurance Needs of Elders) in Orlando. Call them at 407-514-1800 or visit www.SeniorResourceAlliance.org.
Brenda Lyle is a Certified Care Manager and Certified Dementia Practitioner with One Senior Place, Greater Orlando. One Senior Place is a marketplace for resources and provider of information, advice, care and on-site services for seniors and their families. Submit your questions to AskOSP@OneSeniorPlace.com. For immediate help, call 321-751-6771 or visit One Senior Place, The Experts in Aging.
