Appeal of Denials

8.1 - Appeal of Denials (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) A claimant dissatisfied with a contractor’s initial determination is entitled by law and regulations to specified appeals. The appeals process allows a provider and/or a beneficiary (or representative) the right to request a review or reconsideration of the determination to deny a service in full or in part. In this process, Hearing Officers (HOs) and ALJs look to the evidence of record and must base their decision upon a preponderance of the evidence. If the appeal is of a claim reviewed by a UPIC, then the UPIC forwards its records on the case to the AC so that it can handle the appeal. As conclusory statements may be considered of little or questionable value, it is important that reviewers include clearly articulated rationale for their findings. Such clearly articulated rationale will continue to be of importance if a denial is appealed beyond the ALJ level to the Appeals Council or eventually to federal court. Contractors must include a copy of the policy underlying denial in the case file. A. Use of Medical Specialist Reviewers may also use medical specialists to lend more weight and credibility to their rationale or findings. When an adjudicator must weigh the statements and rationale furnished by the appellant provider against the statements and rationale of the reviewer (and any information used by the reviewer), the opinion of a specialist in the same area as the provider may carry greater weight than the opinion of a non-specialist. Consequently, UPICs are required to have a medical specialist involved in denials that are not based on the application of clearly articulated policy with clearly articulated rationale. A review or reconsideration involving the use of medical judgment should involve consultation with a medical specialist. Additionally, contractors are encouraged to use specialists whenever possible since providers are more likely to accept the opinion (and any resulting overpayment) of a specialist in their own area. B. Documenting Reopening and Good Cause Reopening occurs when a UPIC conducts a review of claims at any time after the initial/review determination (see 42 CFR 405.980, (b).) If reopening and conducting a postpayment review occurs within 12 months of the initial/review determination, the UPIC does not need to establish good cause. However, the UPIC should document the date so there is no confusion about whether good cause should have been established. After 12 months, but within 4 years from the date of the initial/review determination, contractors must establish good cause. (See Medicare Claims Processing Manual Pub 100-04, chapter 34 and 42 CFR 405.986. Documenting the date a claim was reopened (regardless of the demand letter issue date) and the rationale for good cause when claims are reopened more than 12 months from the initial/review determination will lend credibility to contractor documentation if the determination is appealed.