Medicare recipients often wonder if a specific prescription drug is covered or if a particular medical procedure will be paid for by their Medicare plans. In order to get these answers, you can simply review your plan’s formulary for prescription medications or review the coverage options under Medicare Part A and Part B. There may be times when you think that something should be covered, but your doctor’s office or pharmacist tells you otherwise. When this occurs, you may need to seek out a coverage determination to receive an exemption.
Understanding a Medicare Coverage Determination
A coverage determination is the decision process used to receive access to medications or medical procedures that may not usually covered by Medicare. In most cases, the standard for receiving an exemption for a non-covered expense is if the medication or procedure is deemed medically necessary by your physician and your doctor has documented the specific information regarding this need.
For example, while things like cosmetic surgery are not covered by original Medicare, a surgical procedure that is usually considered cosmetic may be eligible for coverage after a coverage determination finds that the procedure is required for sustained health. The key here is that the procedure or medication involved must be prescribed or ordered for a non-cosmetic medically necessary reason.
How to File for a Medicare Coverage Determination
The process of filing for a coverage determination usually involves filling out some forms and allowing your physician or specialist to review them. These forms will document your need for an exemption in coverage, so it’s important to work closely with your doctor to determine your level of need. He or she will help you to find the medical options that are best, and if a coverage determination request is necessary, your doctor will know what to include on these forms to help you get coverage where possible.
What Happens If a Coverage Determination is Denied?
Even though filing for a coverage determination is relatively simple, being approved for a covered expense is not guaranteed. The rules that govern Medicare coverage are in place due to research by government officials and insurance providers, so your request will be scrutinized to ensure that you truly are in need of an exemption for a medically necessary reason. Also, just because you receive an exemption for one thing does not mean that you will receive approval for additional exemptions.
Medicare recipients who have their coverage determination requests denied have the right to request a re-determination. This is an appeal and will require your Medicare provider to review your case to ensure that the first decision was correct. It should also be noted that requests can be denied in part or altogether. If a request is denied in part, you may only receive coverage for some of the items in your request. If your request is denied and you are also denied on appeal, you will be left with few options to have your case heard again. One option may be to appeal the decision to a medical board or the Department of Health and Human Services, but taking this approach may lead to a lengthy battle in court.
Do Alternatives Exist?
One of the most common reasons for denial of a coverage determination is if alternative treatment options exist. If they do, especially if they are covered by Medicare, you will almost always have to try these methods before your coverage determination request will be considered. Once again, you need to work closely with your doctor to determine the right course of treatment for your specific needs. You may find that other options exist within Medicare to treat your concerns without the need for filing a coverage determination in the first place.
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