How to Push Back if Medicare or Other Health Insurance Says "No" to Atrial Fibrillation Treatment
You can appeal if Medicare or other health insurance denies coverage for afib medicines or procedures
December 22, 2009 4:13 AM CT
By Peggy Noonan and Mellanie True Hills
If you have a problem getting coverage for the Afib treatment your doctor prescribes, you don’t have to take "no" for an answer. You can push back.
“You have the right to appeal any decision about your Medicare services,” the Centers for Medicare & Medicaid Services (CMS) says, whether you’re covered by Original Medicare, a Medicare Health Plan (such as Medicare Advantage), or a Medicare prescription drug plan. Your rights are also protected if you’re in the hospital, a skilled nursing care facility, a home health agency or a comprehensive outpatient rehab facility.
Let’s take a look first at your Medicare prescription drug rights, followed by Medicare coverage for procedures and then non-Medicare health insurance coverage.
Medicare Prescription Drug Plans
Medicare drug plans cover both generic and brand name drugs, but different plans may have different preferred drug lists. Take the category of beta blockers, which are often used by those with afib for heart rate control or to control high blood pressure. A plan might cover generic metoprolol, but not the equivalent brand-name drug, Toprol-XL®. To get it covered may require an “exception.”
If you’ve been charged too much for a prescription medicine, you were denied a medicine you think should be covered, or you were told you have to accept a different drug than the one your doctor prescribed, you can request a “coverage determination” or "exception." That means you’re notifying the plan of the problem and requesting a correction, such as getting a lower price, getting coverage for a denied prescription, or getting the prescribed drug rather than a substitute.
If you’re not up to handling this yourself, you can designate someone, such as your doctor or a family member, to act as your representative. Medicare recommends that you call your plan to find out how to appoint a representative to take care of your complaints and appeals.
How long will a coverage determination take? For standard requests, your Medicare drug plan has 72 hours from the time they receive your request to notify you of their decision. But if your doctor feels that delaying your medication that long will endanger your health or your life, you can request an expedited review which must be answered in 24 hours. (A supporting statement from your doctor may be required.)
If you need that medication right away and can’t wait for a 24-hour response, you have the right to pay for the medicine yourself and then request a coverage determination and reimbursement from your plan.
If your Medicare drug plan says no, then you have 60 days in which to appeal. Once your plan receives your appeal, they have to notify you of their decision within 7 days for a standard request, or 72 hours for an expedited request.
If you're turned down again, you still have more appeal options—you can request a “reconsideration” (review) by an independent review entity (IRE), followed by a hearing with an administrative law judge, a review by the Medicare Appeals Council, and finally a review by a Federal court.
Original Medicare and Medicare Health Plan Coverage for Procedures
Unlike prescriptions, which can raise coverage obstacles you didn’t expect, procedures are generally pre-certified by doctors’ offices and hospitals. They usually know what needs to be done to get your procedure pre-certified, and if there is a problem getting it approved, they know the appeals procedures for Medicare and other insurance plans.
If you have Original Medicare and your doctor is unable to get a procedure pre-certified, your doctor may give you a notice stating that Medicare may not pay for the procedure. Even in that case, you can still appeal.
If you have a Medicare health plan, such as a Medicare Advantage HMO, PPO, or other type of plan, you can check with your plan to determine if the procedure is covered and to find out how to submit an appeal if it is not.
You have the right to appeal if you feel your Medicare health plan has wrongly denied coverage, refused to pay, limited the payment, or stopped a service. Your plan must give you written information on how to appeal their denial. And you may request an expedited decision if a delay would endanger your health.
If your Medicare health plan still says no, your appeal will be reviewed by an organization that works for Medicare. You can also request help from your State Health Insurance Assistance Program or the Medicare Rights Center, both of which are linked below.
Non-Medicare Health Insurance Plan Coverage
If you’re under 65 and thus not on Medicare, check with your health insurance plan for the process to get medications approved, which will be similar to the process with Medicare.
Getting coverage for afib procedures is less clear as coverage varies from one plan to another. Some plans still consider catheter ablation and minimally-invasive (mini maze) surgery for atrial fibrillation to be experimental. As a result, you or your doctor may need to request a determination or appeal a decision.
In most cases, you will not even need to be involved as your electrophysiologist or surgeon will make the initial request of the insurance plan. If it's unsuccessful, your doctor may submit an appeal as he or she has a vested interest in your procedure being approved. You may also appeal the decision.
The rules for non-Medicare insurance plan appeals vary widely, but if you’ve gone through all available appeal steps and are still having problems, contact your state’s insurance commissioner. They’re listed online or in the government section of your telephone directory.
For More Information:
To learn more about Medicare in general, and your Medicare rights and protections along with how to file Medicare appeals, see:
- Medicare & You 2010 — pages 86–91 deal with Medicare appeal processes
- Your Medicare Rights and Protections
To learn more details about appealing Medicare prescription drug coverage decisions, see:
To find your state insurance commissioner’s office, type " + insurance commissioner" into a search engine, or look up your state here:
For Medicare help, see:
For basic information on coping with health insurance disputes and problems, see ConsumerReportsHealth.org’s tips on how to dispute and negotiate charges and how to get help:
- Dispute and negotiate charges, Insurance, ConsumerReportsHealth.org
- Get help, Insurance, ConsumerReportsHealth.org
Peggy Noonan specializes in writing about health for consumers and medical professionals. She writes for leading national magazines and consumer publications as well as StopAfib.org.
Mellanie True Hills is founder and CEO of StopAfib.org and an atrial fibrillation survivor.