Overcoming Medicare Advantage Denials

What You Need to Know

Despite the fact that Medicare Advantage plans are supposed to follow established Medicare coverage criteria for orthotic and prosthetic claims, we continue to speak to suppliers who are forced to appeal denials of claims that Traditional Medicare deems covered based on existing Local Coverage Determinations. In those situations, remember that established Medicare policy requires MA plans to follow Traditional Medicare's coverage policies:

• "CMS regulations at § 422.101(a) and (b) require that … MA plans must comply with Traditional Medicare national coverage determinations (NCDs) and local coverage determinations (LCDs) applicable in the MA plan’s service area.” [emphasis added] (p. 66) 
• “MA organizations must cover all Part A and B benefits … on the same conditions that items and services are furnished in Traditional Medicare. This means that MA organizations may not limit coverage through the adoption of policies and procedures … when those policies and procedures result in denials of coverage or payment where the Traditional Medicare program would cover and pay for the item or service furnished to the beneficiary. [emphasis added] (p. 67)
• Medicare has a “longstanding policy that MA organizations may only apply coverage criteria that are no more restrictive than Traditional Medicare coverage criteria found in NCDs, LCDs, and Medicare laws.” [emphasis added] (p. 70).

What this Means for You

When you receive a MA plan denial, look for the coverage criteria cited or the Medical Policy referenced by the MA plan. Confirm that the standards listed are no more restrictive than those in the applicable LCD. Sometimes the MA plan's criteria appear to be similar to Medicare's but on closer analysis are more restrictive. If you determine that the MA plan denied a claim that Traditional Medicare would have paid for, your appeal should reference the language quoted above.

Remember though, that MA plans can create coverage standards in instances where no National Coverage Determination or Local Coverage Determination/Policy Article exists. A MA Plan could, for example, establish its own criteria for upper limb prostheses, as no NCD or LCD exists for those devices.

And remember, health care providers win more than 80% of the time when they appeal a MA plan's denial of authorization. These numbers make clear that you should stand up for your patient's rights to access the services you provide, especially when a MA Plan refuses to authorize them.