“Medicare denied the drug” is not enough information to build the next step. A patient can receive Part B coverage through Original Medicare or through a Medicare Advantage plan, and the appeal route is different.

Step 1: identify the decision maker

If the patient has Original Medicare, coverage and payment decisions follow the Original Medicare claims and appeals process. If the patient is enrolled in Medicare Advantage, the private Medicare plan makes an organization determination and uses the Medicare Advantage reconsideration process.

Pull these items together before responding
  1. The actual denial, organization determination, Medicare Summary Notice or claim response.
  2. The exact medicine, formulation, dose and treatment date or requested start date.
  3. The diagnosis and the coverage criterion the payer says was not met.
  4. The current payer or Medicare policy used for the decision.
  5. Relevant clinical records and prior-treatment history.
  6. The deadline and submission instructions printed on the notice.

Step 2: answer the actual reason for denial

An appeal is stronger when it addresses the specific problem. A denial may involve medical-necessity criteria, missing documentation, a preferred product, coding, site of care, network status or another administrative requirement. Fixing an administrative defect can be different from disputing a substantive coverage decision.

Medicare Advantage Part B drug reconsiderations

Medicare says Medicare Advantage coverage decisions are called organization determinations. If the member disagrees, the member or representative can request reconsideration. Current Medicare guidance lists a 7-day standard decision timeframe for Part B drug appeals and a 72-hour fast-appeal timeframe when the health-risk standard for expedited review is met.

Original Medicare appeals

Original Medicare has a separate multi-level appeal process. The Medicare Summary Notice or other decision notice explains the first appeal step and filing deadline. The exact process depends on whether the dispute is about coverage or payment and where the case is in the appeal chain.

Financial assistance is a separate track

A foundation grant or manufacturer assistance program may help with eligible out-of-pocket costs, but it does not convert a non-covered claim into a covered claim. Work the coverage denial and the affordability problem as two related but separate tasks.

Official sources

Medicare.gov — Filing an appeal →Medicare.gov — Appeals in Medicare health plans →