What must a Medicare denial letter tell you?
A Medicare denial notice must give the reasons, say whether a local or national coverage policy was applied, explain how to obtain more information such as the provision used, and set out your appeal rights. It must be written to be understood. It does not have to quote the rule itself.
The answer is no. Somewhere behind that one word is a rule, and the letter in your hand is not going to give it to you. It does not have to. What it does have to do is narrower than most people expect and far more useful than most people know.
A daughter is holding that letter this week. A neighbour is on the phone to a plan at nine in the morning. A volunteer at a benefits desk has read a hundred of these and wants to know what the law actually requires. The answer runs the same for all three.
Contents
What must a denial letter tell you?#
Four things. They sit together in one section of the Code of Federal Regulations (CFR), the book of standing federal rules.
The section is 42 CFR 405.921. Write that number down. It is the provision your own letter had to be built from.
Read your page against that list first. It is a better opening move than reading for the answer.
Four duties, in one place:
- The reasons. Including which policy applied.
- The procedures. How to obtain the provision.
- Your appeal right. And how to use it.
- Anything else the agency requires.
One page, four duties. Check the page against them before anything else.
A letter that skips one has not done its job. That is worth saying out loud in an appeal, calmly, once.
Notice what is not on the list. The rule itself. A letter can satisfy all four duties and still leave you without the provision that decided your claim. That is the next section.
Two minutes with this list is also diagnostic. It tells you whether you are arguing about the decision or about the paperwork, and those are different appeals with different odds.
Does the letter have to name the rule?#
No. The letter names the kind of policy and stops there, and that gap is where most people stop too.
The regulation requires the letter to say which kind of coverage policy was applied. A local medical review policy, a local coverage determination, or a national one. So you learn that a policy exists. You learn what kind it is.
Then, separately, it must give you the procedures for obtaining more information. The regulation offers an example, and the example is the one you want: the specific provision of the policy, manual, law or regulation used.
Note the wording. Such as, not namely. The provision is an example of the additional information rather than the whole of it, so the entitlement sits looser than it first reads.
Read those two together and the shape appears. The rule is obtainable, not supplied.
That is a smaller promise than it sounds and a bigger right than it looks. The provision is yours for the asking. Nobody will volunteer it, because nobody is required to, and a busy office does not do unrequired work.
Think of it like a restaurant that must post that it has an inspection certificate without hanging the certificate on the wall. You are entitled to see the paper. Somebody has to ask for it, and that somebody is you.
Which sort of policy was applied matters more than it seems, because national and local determinations carry opposite force. The letter names which. That one word on the page decides what kind of appeal is worth an evening of your time.
What does the letter mean by the reasons?#
Something specific, not something general. The regulation asks for the reasons for the determination, and the word doing the work is the plural.
A page saying the service was not medically necessary has given you a conclusion. A page naming which policy was applied and what that policy required has given you a reason.
The difference is not stylistic. One can be argued with. The other can only be disagreed with, and a reviewer is free to decline a disagreement.
So sort what you find as you read. Conclusions in one hand. Reasons in the other. If the second hand is empty after a careful read, that is the first thing to put in writing.
Do it with a pen, on the letter itself, marking the two kinds as you go.
Ten minutes at a kitchen table turns a wall of text into a short list. Short lists get answered.
What changes inside a Medicare Advantage plan?#
A private company writes the letter, so a different section governs it: 42 CFR 422.568.
It requires approved notice language in a readable and understandable form. It requires the specific reasons for the denial. It requires the plan to tell you about your right to a reconsideration.
Then it requires something people miss, and it depends on what was denied.
Deny a service, an item or a Part B drug, and the plan must describe both the standard and the expedited reconsideration processes. It must include the conditions for getting an expedited one.
Deny a payment, and it must describe only the standard process and the rest of the appeal path.
So the expedited route is a duty on some letters and not on others. If care was refused, that paragraph should be on your page. If a bill was refused, it need not be, and its absence is not a failing.
Look for the word expedited first, and know which kind of denial you are holding before you decide the letter left something out.
If the situation is urgent, that paragraph matters more than the rest of the letter. In the letters I have read, it is usually the one printed smallest.
What if the letter is impossible to understand?#
Then the letter has a problem, and the regulation is on your side about it.
The rule says the notice must be written in a manner calculated to be understood by the beneficiary. Not accurate. Not complete. Understood.
That is a legal duty rather than a courtesy, and it changes the tone of the whole conversation. A person who cannot follow their own denial letter is not failing a test. The page is.
Like a prescription nobody can read, the document may be perfectly correct and still fail at the only job it had. The pharmacist does not shrug and hand it back. The pharmacist rings the surgery.
So write the sentence. Say the notice did not let you tell what was decided or why, and ask for the provision in the same breath. Both requests sit in one regulation, a paragraph apart, which makes them one letter rather than two.
What can you do with the letter you have?#
Four moves, in order, and none of them needs a lawyer.
Read the letter against the four duties it owes you. Note which sort of coverage policy it names, because that decides your ground. Ask in writing for the specific provision it used. Check the date printed on the page, because your clock started there rather than on the day you opened the envelope.
Put every request in writing. A written request outlives a change of staff and a year of delay. A written answer gives you something you can hold up later.
Then go and read what comes back. The five parts of Title 42 tell you which room the provision lives in. The pillar on reading the federal rulebooks covers the rest.
A parent at the kitchen table can do all four in one evening, with a pen and the letter and nothing else.
The rule behind the decision is not hidden. It is just not enclosed, and those are very different problems to have.