The managed care model of health insurance seeks to keep their expenses low by limiting the providers a patient may see and the types of treatment it will cover.  At times, this is a frustrating for patients and sometimes keeps them from the most appropriate care.  Medicare Advantage operates under a similar model and can deny you treatment even though it has been recommended by your doctor.  However, when you are denied care by Medicare Advantage, there are steps you can take to advocate for your treatment.

Under Medicare Advantage your treatment and proposed treatment is reviewed by plan administrators who can refuse coverage on the basis that the proposed procedure or treatment is medically unnecessary or experimental.  This can also apply to previously approved Medicare services you are already receiving.  Your appeal process for these denials will go as follows:


Once denied a service you will receive written notice which begins the clock for how long you have file your appeal.  If 14 days pass without this notice, you can proceed with your appeal.  If you and your doctor feel that waiting for the treatment would place you at risk, you may request permission to expedite your appeal.  If your request is granted the Medicare will notify you within 72 hours.

The Appeal

The appeal process can be up to five stages depending on if you have success:

Level 1: First, you must file your appeal within 60 days which states your arguments and provides supporting documentation.  Typically, a decision will be issued within 30 days for a denied service and 60 days for an existing service or 72 hours for an expedited appeal.

Level 2: Review by an Independent Review Entity (IRE):  If your appeal is denied you will receive another written notice and the plan should automatically forward the appeal to the next level of review the IRE who should decide within 30 days or 60 days for an existing service.

Level 3: Administrative Law Judge (ALJ):   If your IRE appeal is denied and your service or item is worth a certain amount, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA) level to be heard by an ALJ.

Level 4: Medicare Appeals Council (Appeals Council):  If your OMHA appeal is denied and your service is worth a certain amount, you can appeal to the Appeals Council.

Level 5:  If these steps do not work, you can appeal to a court of law.

Unfortunately, advocating for your medical treatment and care is sometimes necessary and often involves a complicated process.  Effective advocacy at each level of appeal can be the difference between you receiving essential care or having to go without your treatment.  Our office has attorneys who are knowledgeable about Medicare and can help you understand your choices and make informed decisions about how to best evaluate and prepare your case.   Please contact us if we may be of assistance.

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