Medicare Advantage denied care as not reasonable and necessary. What does that mean?
In Medicare Advantage, 'not reasonable and necessary' means the plan says the service does not meet Medicare coverage standards or accepted medical-necessity criteria for this patient. Appeal by asking which Medicare rule, local coverage determination, or internal criterion was applied and showing how the patient's record meets it.
What to do, in order
- Step 1
Ask for the rule used
Request the Medicare coverage rule, local coverage determination, national coverage determination, or internal criterion the plan relied on.
- Step 2
Use the individual-circumstances rule
MA plans must consider the individual's circumstances and cannot deny solely by algorithm or a stricter internal rule.
- Step 3
Get the treating clinician's explanation
The letter should tie symptoms, diagnosis, prior treatments, risks, and expected benefit to the Medicare or plan criteria.
- Step 4
Move up the five-level ladder
If the plan upholds, it forwards or you request review by the independent review entity, then ALJ and beyond if the amount is high enough.
The deadline that applies
Medicare Advantage reconsideration requests are generally due within 60 calendar days after the notice is received, with receipt presumed 5 days after the notice date unless shown otherwise (42 CFR 422.582). Expedited reconsiderations are available when delay could seriously jeopardize health.
Calculate your date →Documents to gather
- MA denial notice
- Coverage rule or criteria
- Medical records
- Treating clinician statement
- Any algorithm or utilization-management notes obtained
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Related questions
Can a Medicare Advantage plan use stricter rules than Medicare?
It generally must cover Medicare-covered benefits and follow applicable Medicare coverage rules, while considering the individual's circumstances.
What if the plan says an algorithm predicted recovery?
Ask for the tool and reviewer information, and argue the decision must be individualized and clinician-reviewed.
How fast is an expedited MA appeal?
Generally 72 hours when the case qualifies for expedited review.
Sources
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