Medicare Denied Your Specialist Referral?
Published data shows denial and appeal outcomes vary by plan, product year, denial reason, and documentation. Use this page to spot the issues to request and the evidence to gather before you decide what to submit.Sources include KFF ACA Marketplace Transparency Data, HHS OIG reports, and state insurance department filings. Aggregate rates are context, not predictions for an individual case.
Based on published government and industry research. Individual results vary based on denial type, insurer, and documentation.
Why they said no
Why Medicare Denies Specialist Referral
Primary care can manage the condition
Out-of-network specialist not covered
Referral authorization expired or not obtained
Medicare patterns
Medicare's Common Denial Patterns
Denying claims as not reasonable and necessary
Coverage determinations based on LCD/NCD criteria
Denying skilled nursing facility stays as custodial care
What works
How to Strengthen Your Specialist Referral Appeal
PCP letter explaining why specialist care is needed
Documentation of failed primary care treatment
Evidence no in-network specialist is available for the condition
Your rights
Laws That Protect You
ACA network adequacy requirements
State any-willing-provider laws
No Surprises Act for emergency specialist care
Playbook
Tips for Appealing to Medicare
Medicare has a 5-level appeal process with different evidence and deadline rules at each level
Request an ALJ hearing if redetermination and reconsideration fail
Cite specific LCD/NCD criteria and explain how your case meets them
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Related denial guides
More Medicare denials
Specialist Referral denials by other insurers
This information is for educational and informational purposes only. It does not constitute legal or medical advice. Statistics cited are from publicly available sources including KFF, HHS OIG, and state insurance department data. Individual results may vary. Consult a qualified professional before taking action on your specific situation.