Medicare Denied Your Specialist Referral?
Centers for Medicare & Medicaid Services (CMS) denies 18% of claims on average. But 75% of appeals succeed when patients fight back. Your specialist referral denial may have grounds for a successful appeal.
Why Medicare Denies Specialist Referral
Primary care can manage the condition
Out-of-network specialist not covered
Referral authorization expired or not obtained
Medicare's Common Denial Tactics
Denying claims as not reasonable and necessary
Coverage determinations based on LCD/NCD criteria
Denying skilled nursing facility stays as custodial care
How to Win 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
Laws That Protect You
ACA network adequacy requirements
State any-willing-provider laws
No Surprises Act for emergency specialist care
Tips for Appealing to Medicare
Medicare has a 5-level appeal process — most denials are overturned by level 2 or 3
Request an ALJ hearing if redetermination and reconsideration fail
Cite specific LCD/NCD criteria and explain how your case meets them
Ready to Fight Your Specialist Referral Denial?
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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.