When Medicare denies coverage for items or services because they are not medically reasonable and necessary, or you do not meet Medicare's coverage criteria, Medicare will still pay if neither you nor the provider knew, and could not reasonably be expected to have known, that the items or services would not be covered.
When you did not have such knowledge, but the provider knew, or could have been expected to know that the items or services were not going to be covered by Medicare due to lack of medical necessity, the provider is responsible for the charges for the denied items or services. This includes all health care providers and durable medical equipment suppliers.
When you knew or could have been expected to know that the items or services were not going to be covered, you are responsible for the charges for the denied items or services. Medicare makes this decision based on whether it previously notified you that the service or item was not covered, or whether you signed an Advance Beneficiary Notice (ABN). If Medicare decides that you are liable for the charge, then the provider can bill you its usual and customary charges and is not limited to charging Medicare’s allowable amount, even if the provider accepts assignment.
Remember that you can always appeal Medicare’s decision. However, if you lose the appeal, you will be liable for payment.
For more information on what to do if Medicare denies coverage and your appeal rights, click on the link in the GO TO box.