Home · Medicare coverage

Medicare coverage denial

Medicare denied payment? A physician can review the denial.

A licensed physician reads the denial, your medical records and the coverage criteria that were applied, so you can understand whether further appeal options may be available.

Get Help With My Medicare Denial Check my denial first · 60 seconds →

No account needed to check. A physician tells you candidly if the case has no merit.

What this denial means

A Medicare denial is a decision about criteria, and the levels continue above it.

A Medicare denial says the service your doctor ordered did not meet Medicare's coverage criteria as the paperwork presented it. For a lab test that is often a diagnosis code that did not match the indications in a coverage determination, documentation that never reached the reviewer, or a frequency limit applied without the clinical reason the test was repeated.

Medicare appeals run in levels, and a decision at one level is not the end of the sequence. Filing windows are commonly 120 days from the Medicare Summary Notice under Original Medicare, and commonly 60 days from the notice under Medicare Advantage and Part D, with shorter windows where an expedited decision is requested. A denial your provider appealed and lost is therefore not necessarily a denial that has run out of levels, and the work at the next one is the same work: the criteria that were applied, set against the clinical record. The notice you received is the authority on which level you are at and how long you have.

What the letter argues

Written by a licensed physician, cited line by line.

The coverage criteria that applied

Medicare's contractors decide from published national and local coverage determinations. The letter names the one at issue and walks your record against it, rather than asking generally for reconsideration.

Your record, in full

The chart the reviewer never saw: the diagnosis behind the order, what has already been tried and what it showed, and why your physician asked for this service.

What the earlier appeal left unanswered

Where your provider has already appealed, the letter reads that decision and addresses the specific ground it turned on, with the medical evidence that speaks to it.

Guidelines and evidence

Specialty-society guidelines, labeling and peer-reviewed literature supporting the service your physician ordered. Each one cited, so nothing rests on assertion.

Resources

Not ready to start a case? That’s okay. Start here.

Start hereYour insurance denied a medication or treatment: what to do in the next 48 hoursA denial letter starts a clock. Here is what to read, what to request, and what to gather in the two days after it arrives, in the order it usually matters.Read the Guide →

Explore All Guides →

Getting started

From your Medicare notice to a physician-signed appeal, in four steps.

Tell us what happened

Share your denial and some basic information about the medication or treatment your doctor recommended. Don’t worry if you don’t know exactly what kind of denial you have.

We review your case

A licensed Cove Health physician reviews your information, the reason for the denial, and the medical and coverage criteria that may apply to your case.

We build the case for your care

Your Cove Health physician uses medical evidence, clinical guidelines, and Cove Health’s technology to develop a clear, well-supported case for the care your doctor recommended.

We help you take the next step

We help you understand what comes next and advocate on your behalf based on the needs of your case.

Appeal deadlines are set by your health plan and/or applicable law, and you remain responsible for meeting them. Submitting a case does not guarantee that an appeal can be completed or filed before your deadline unless Cove expressly confirms otherwise.

Simple, honest pricing

One issue or many, we've got you.

Single Case

One issue, fully handled: review, drafting, and advocacy.

$100 flat fee

✓ Licensed physician review of your records
✓ One fully drafted, guideline-cited advocacy letter
✓ Sent to the party of your choice
✓ No subscription, no commitment

Start my case

Best for ongoing needs

Cove Membership

For patients juggling multiple issues across plans and providers.

$29.99 / month

Two-month minimum, then month to month

✓ Ongoing advocacy across multiple issues
✓ Priority physician review
✓ Unlimited letters while subscribed
✓Continuous case tracking & follow-ups

Become a member

The membership starts with a two-month minimum commitment. If you cancel during those first two months, the remaining balance for the commitment is still due and will be charged. After the initial two months it continues month to month until you cancel.

Cove Health provides non-legal patient advocacy. We are not a law firm and do not provide legal representation.

Frequently asked questions

Medicare coverage denials, answered.

Does Cove Health help with Medicare denials? +

Yes. Cove Health offers physician-led advocacy for Medicare coverage and payment denials. We review the reason for the denial, your medical records, and the applicable coverage criteria to assess how we may be able to help. Support may include a physician-signed advocacy letter and guidance on available next steps. Your options depend on your coverage, the issue involved, and where you are in the appeals process.

My provider already appealed, and Medicare still denied coverage. Can Cove Health help? +

An unsuccessful appeal does not always mean the process is over. Cove Health can review the original denial, the previous appeal, and the latest decision to assess whether further review may be available and what medical evidence could support your case. Available options depend on the appeal stage, applicable requirements, and filing deadlines.

I have Original Medicare and a Medicare supplement. Can Cove Health still help? +

Yes. Having Medicare Supplement Insurance, also called Medigap, does not prevent you from seeking our help. Medigap generally helps pay your share of costs for services covered by Original Medicare. If Medicare denies the underlying service, Cove Health can review that decision and the medical evidence relevant to challenging it.

What if I need the same test or treatment again soon? +

Please tell us about your upcoming appointment and any appeal deadlines when you contact us. We can review the previous denial and help identify questions or documentation to discuss with your provider before your next service. An appeal of a previous claim does not guarantee coverage for a future service, and we cannot guarantee a decision before your appointment.

What documents should I provide for a Medicare denial review? +

Please provide your Medicare Summary Notice or denial letter, any appeal decisions, copies of previous appeal submissions if available, and relevant medical records or your provider's explanation of why the service is needed. Include any upcoming testing or treatment dates and deadlines listed in your notices. Documents should be submitted through Cove Health's secure intake process.

Still have a question?

Common insurance problems

Facing a different denial?

“Your care isn’t medically necessary.”Medical necessityYour insurer says the medication or treatment your doctor recommended does not meet its criteria for medical necessity.How Cove Health can help →“Your care needs approval first.”Prior authorizationYour insurer requires approval before it will cover your medication or treatment, and that approval has been delayed or denied.How Cove Health can help →“You need to try something else first.”Step therapyYour insurer requires you to try another medication or treatment before it will cover the one your doctor recommended.How Cove Health can help →“Your medication isn’t covered.”Formulary exceptionYour medication may not be on your insurance plan’s covered drug list, or your insurer may require an exception before it will cover it.How Cove Health can help →

Next step

Put a physician in your corner today.

Get Help With My Medicare Denial Read the FAQ →