f you have a Medicare Advantage plan, your plan may overrule your doctor and refuse to cover a treatment or procedure that it deems to be medically unnecessary or experimental … However, there is an appeal process to resolve these conflicts.
Medicare Advantage plans can make certain decisions regarding their plans and what will be covered, as they should. After all, this discretion is what keeps them in business and from being “gamed” by scammers. That noted, the plans are not always right when exercising their discretion to deny doctor-prescribed treatments or procedures.
If you (or a loved one) have a Medicare Advantage plan, then it is important to be prepared should the plan itself overrule your doctor and deny you coverage. That certainly would be an unfortunate turn of events! Fortunately, you can seek to overrule coverage denied by your Medicare Advantage plan, but you must know how.
While you can be denied coverage, it is important to remember that the Medicare Advantage plan is not the final arbiter and you can appeal their decision. This is an important right built into the very structure of Medicare. A timely article in ElderLawAnswers.com titled “Appealing Medicare Advantage Plan Decisions” provided some insights into this process.
Did you know that above every Medicare plan is the judicial oversight of an Administrative Law Judge (ALJ)? When the plan makes an adverse coverage decision, first you should appeal to their better judgment. If you are unsuccessful, then you can go over their heads and appeal to the ALJ.
But wait, there is more. If you are unsuccessful before the ALJ, then go even higher to the Medicare Appeals Council (MAC). Be aware, however, that at this level the process becomes a matter of litigation and all that entails time and money. Nevertheless, litigation is sometimes a necessary evil to pursue necessary care (and justice).
You may never need to challenge a denial of coverage. In case you do, however, it is best to be prepared and that means being well-informed regarding your rights.
Reference: ElderLawAnswers.com (last modified September 26, 2013) “Appealing Medicare Advantage Plan Decisions