Medicare Advantage Plan Wrongful Denials? What You Can Do

What You Need to Know

In a 2023 Final Rule, CMS stated that Medicare Advantage plans must follow Traditional Medicare 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) 
• “As originally stated in the June 2000 final rule [ ], 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 that you believe Traditional Medicare would have covered, you must carefully review the denial letter. In particular, look for the coverage criteria cited or the Medical Policy referenced by the MA plan. Analyze it closely, confirming that the standards listed are no more restrictive than those in the applicable LCD or Policy Article. We have seen many examples where the MA plan's standards look similar to LCD/PA criteria but are actually 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.

However, MA plans can create coverage standards in instances where no National Coverage Determination or Local Coverage Determination/Policy Article exists. For example, upper extremity prostheses do not currently have a NCD or LCD/PA that set forth relevant coverage criteria. A MA plan applying its own criteria would therefore have the authority to do so when dealing with upper extremity prosthetic claims.

If you receive a MA plan denial, don't just give up. Follow the steps in this article and appeal using the language from the Final Rule referenced above whenever it applies.