If you have been denied coverage for a health service or item, you should appeal this decision. An appeal is when you ask Medicare or your plan to reconsider its coverage decision. You can appeal whether you have Original Medicare, a Part D prescription drug plan, or a Medicare Advantage Plan.
Before you start your appeal, make sure you fully read all the letters you receive from Medicare or your plan. Contact Medicare or your plan to find out the reason your health service or item is not being covered, if the information has not been provided. Specifically mentioning the reason for denial in your appeal letter will increase the chance of winning your appeal. Additionally, appeals are more successful if you have a doctor’s letter of support that also specifically mentions the reason for denial.
There is more than one level of appeal, and you should continue appealing if you are not successful at the first level. Appeal levels and timeframes differ. Make sure you follow the steps and stay within the timeframes of the appeal process that applies to your situation. If you do not follow these rules, your appeal may not be considered.
Keep in mind that an appeal is different from a grievance. A grievance is an official complaint that you file with your plan.
Use the links below to navigate to the section of Medicare Interactive that reviews the relevant appeals process.
- Original Medicare Appeals – This section includes information about how to appeal if you have Original Medicare.
- Medicare Advantage Appeals – This section includes information about how to appeal if you have a Medicare Advantage Plan. Keep in mind that there is one process for when you have not yet received your service and a different process for when you have already received your service.
- Part D Prescription Drug Appeals – This section includes information about how to appeal for coverage of prescription drugs. You follow the same process if you have a stand-alone Part D plan or if you have a Medicare Advantage Plan that includes your Part D prescription drug coverage.
- Premium Appeals – This section includes information about how to appeal if you have a higher Part B or Part D premium due to a higher income.
If you have additional questions about the appeals process, learn more about the resources that exist to help you understand your rights.