Page Reviewed / Updated – August 12, 2020

Medicare Advantage plans are required to offer the same coverage as Medicare Parts A and B, and often provide expanded coverage options. However, Medicare Advantage plans do not guarantee coverage in all circumstances. Factors like medical necessity, in-network vs. out-of-network providers and procedure pre-approval play an important role in whether or not a claim is denied. Read below for specific Medicare Advantage Plan coverage details.

Understanding Denials With Medicare Advantage

Medicare Advantage plans are generally available to anyone who is eligible for Medicare Parts A and B, with the exception of those with end-stage renal disease. However, Medicare Advantage plans don’t offer guaranteed coverage under all circumstances.

When Can’t a Medicare Plan Deny Coverage?

The services included in Medicare Advantage plans are usually covered without the risk of denial. There are also specific circumstances in which denial is explicitly prohibited.

Treatment under these Medicare plans can’t be denied if:

  • It was pre-approved
  • There is no express justification given for denial
  • Necessary care must be performed by an out-of-network provider when no in-network provider is available
  • Necessary treatments are expressly included in a plan, even if they relate to pre-existing conditions

When Can a Medicare Plan Deny Coverage?

Coverage can be denied under a Medicare Advantage plan when:

  • Plan rules are not followed, like failing to seek prior approval for a particular treatment if required
  • Treatments provided were not deemed to be medically necessary
  • An out-of-network provider was used when an in-network alternative was available
  • Treatment was received through participation in a clinical trial, depending on plan coverage details and prior approval from an insurance company

The most common reason for the denial of a claim involves the determination of medical necessity. In some cases, a medication or procedure a care provider deems important isn’t seen this way by an insurance company. When this occurs, a care provider may need to provide proof of the value of a particular treatment over available alternatives. This can be the case with medications under Medicare Advantage plans that offer prescription drug coverage. Should this occur, it may be necessary to try other medications before resorting to a more costly drug if agreed upon by a provider.

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Appealing a Denial of Coverage

If a Medicare Advantage insurance claim has been denied, it’s possible to file an appeal. The procedures for appeal can differ from one provider to another, so it’s vital to fully review the plan documentation before starting this process. An appeal typically entails filing paperwork with the insurance company, and may require a physician’s letter regarding the necessity or nature of a particular treatment.

Following the rules of a Medicare Advantage plan can help avert denials for coverage, including seeking preapproval for procedures, exhausting in-network options before seeking alternatives and reviewing medical necessity with a provider before moving forward.