<#if page.ID == "About"> In This Section
<#else> View Our Practice Areas

Appealing Denial Of Medicare Treatment


If 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.

No Comments

Leave a comment
Comment Information
Email Us For A Response

Find Out The Difference That Experience And Expertise Makes

Get the peace of mind that you deserve. First, attend a seminar. This will entitle you to a free initial consultation and a discounted estate planning fee. To learn more about our services or sign up for a seminar, contact us online or call us at 866-402-1805. We have offices in Torrance, Orange, Newport Beach, Pasadena and Woodland Hills.

Questions? Contact Us.

Bold labels are required.

Contact Information

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.


Privacy Policy

Call Now For A Free Consultation: 866-402-1805
  • ${site.data.firmName}${SEMFirmNameAlt}
  • Main Office: Torrance

    Torrance Office
    990 West 190th Street
    Suite 500
    Torrance, CA 90502

    Toll Free: 866-402-1805
    Map & Directions

    Orange Office
    333 City Boulevard West
    17th Floor
    Orange, CA 92660

    Toll Free: 866-402-1805
    Map & Directions

    Newport Beach Office
    5000 Birch Street
    Suite 8000
    Newport Beach, CA 92660

    Toll Free: 866-402-1805
    Map & Directions

    Pasadena Office
    790 East Colorado Boulevard
    9th Floor
    Pasadena, CA 91101

    Toll Free: 866-402-1805
    Map & Directions

    Woodland Hills Office
    5850 Canoga Avenue
    4th Floor
    Woodland Hills, CA 91367

    Toll Free: 866-402-1805
    Map & Directions

    Office map