Medicare Appeals Guide for Joint Pain Treatments

Understanding Your Right to Appeal

When Medicare denies coverage for your joint pain treatment, you have the right to appeal that decision. Many denials are overturned on appeal—but only if you take action.

Key Statistics:

• 40-50% of Medicare appeals are successful at the first level
• Higher success rates at external review levels
• Most people never appeal, missing opportunities for coverage

This guide walks you through the entire appeals process, from understanding why your claim was denied to building a winning case.

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Common Reasons for Joint Pain Treatment Denials

HA Injection Denials

Frequent Denial Reasons:

1. “Not medically necessary” - Insufficient documentation of OA severity or failed conservative treatment
2. “Frequency limit exceeded” - Requesting injection too soon after last series
3. “Step therapy not followed” - Didn’t try required treatments first
4. “Prior authorization not obtained” - Especially common with Medicare Advantage
5. “Wrong diagnosis code” - Coding error on the claim

Physical Therapy Denials

Common Issues:

• Progress not adequately documented
• Goals not clear or measurable
• Treatment extending beyond “reasonable” duration
• Maintenance therapy vs. skilled therapy

Injection Guidance Denials

• Ultrasound/fluoroscopy guidance denied as “not necessary”
• Documentation didn’t justify imaging use

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The 5 Levels of Medicare Appeals

Overview

Level	Who Reviews	Timeline to File	Decision Timeline
1. Redetermination	Medicare contractor	120 days	60 days
2. Reconsideration	QIC (independent)	180 days	60 days
3. ALJ Hearing	Administrative Law Judge	60 days	90 days
4. Medicare Appeals Council	Appeals Council	60 days	90 days
5. Federal Court	U.S. District Court	60 days	Varies

Most appeals are resolved at Levels 1-2. Few cases need to go beyond.

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Level 1: Redetermination

What It Is

Your first opportunity to have Medicare’s initial decision reviewed. A different person at the Medicare contractor re-examines your claim.

How to File

Step 1: Get the Decision Notice

• Called “Medicare Summary Notice” (MSN) or “Remittance Advice”
• Review carefully—understand exactly why it was denied
• Note the deadline (120 days from the date of the notice)

Step 2: Request Redetermination Write a letter or complete CMS Form 20027 including:

• Your name, Medicare number, date of birth
• Date of service being appealed
• Claim number and service description
• Why you believe the decision was wrong
• Request for specific action (pay the claim)

Step 3: Attach Supporting Documentation

• Copy of the denial notice
• Medical records supporting medical necessity
• Doctor’s letter explaining why treatment was needed
• Peer-reviewed articles (if applicable)

Step 4: Submit

• Mail to address on denial notice
• Keep copies of everything
• Send certified mail with return receipt

Tips for Level 1 Success

• Be specific: Address the exact reason for denial
• Provide evidence: Include documentation you may have missed initially
• Get doctor’s help: Their supporting letter is often crucial
• Meet deadlines: 120 days goes quickly

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Level 2: Reconsideration (QIC Review)

What It Is

If Level 1 is unsuccessful, an independent Qualified Independent Contractor (QIC) reviews your case. This is a fresh review by reviewers not connected to the original decision.

How to File

Within 180 days of Level 1 decision:

• Complete CMS Form 20033
• Include all previous documentation
• Add any new evidence or arguments
• Submit to the QIC listed on your redetermination decision

Why Level 2 Often Works

• Independent reviewers with medical expertise
• Fresh perspective on your case
• Often more thorough than Level 1
• Can request medical records directly from providers

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Level 3: Administrative Law Judge (ALJ) Hearing

What It Is

A hearing before an Administrative Law Judge where you can present your case in person, by phone, or video.

Requirements

• Must have at least $180 in dispute (2024 threshold)
• Must request within 60 days of Level 2 decision
• Submit CMS Form 20034

The Hearing Process

Before the Hearing:

• Receive notice of hearing date
• Submit any additional evidence at least 5 days before
• Prepare to explain your case clearly

During the Hearing:

• Judge reviews all documentation
• You can present your case (or have representative)
• Doctor can testify (in person or by letter)
• Judge asks questions

After the Hearing:

• Written decision within 90 days
• If successful, claim is paid
• If denied, can appeal to Level 4

Tips for ALJ Success

• Prepare a clear, organized presentation
• Have your doctor’s support documented
• Bring copies of all relevant records
• Consider having a representative assist you

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Building Your Appeal Case

Essential Documentation

Medical Records Must Show:

1. Diagnosis confirmation

   • X-ray or MRI results
   • Clinical examination findings
   • ICD-10 code for osteoarthritis

2. Conservative treatment history

   • Physical therapy dates and outcomes
   • Medications tried and results
   • Other treatments attempted

3. Functional limitation

   • How OA affects daily activities
   • Pain levels and their impact
   • Work or activity restrictions

4. Medical necessity

   • Why this specific treatment is needed
   • Why alternatives aren’t appropriate
   • Expected benefits

Sample Letter of Medical Necessity

Your doctor should provide a letter including:

To Whom It May Concern:

I am writing to support the medical necessity of [treatment] for
[patient name], my patient with documented knee osteoarthritis.

DIAGNOSIS:
Primary osteoarthritis, right knee (M17.11), confirmed by X-ray
showing [findings] on [date].

FAILED CONSERVATIVE TREATMENT:
- Physical therapy: [dates] with insufficient relief
- NSAIDs: Tried [medications] with [results]
- Activity modification: Ongoing but inadequate

FUNCTIONAL IMPACT:
Patient cannot [specific activities] due to pain, significantly
affecting quality of life and independence.

TREATMENT RATIONALE:
Viscosupplementation is appropriate because [clinical reasoning].
Expected benefits include [specific outcomes].

This treatment is consistent with ACR/AAOS guidelines for OA
management and is medically necessary for this patient.

Sincerely,
[Doctor's name and credentials]

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Medicare Advantage Appeals

Key Differences

Medicare Advantage (Part C) plans have their own appeals process:

Organization Determination → Reconsideration → IRE → ALJ → MAC → Court

Important Notes

• Tighter timelines in many cases
• Plan must provide expedited review for urgent situations
• Can request external review (IRE) after plan reconsideration
• Same appeal rights, different process

Common MA Issues

• Prior authorization denials more common
• Network restrictions affect coverage
• Step therapy requirements stricter
• Documentation requirements may differ

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Getting Help with Appeals

Free Resources

State Health Insurance Assistance Program (SHIP):

• Free counseling in every state
• Help with Medicare questions and appeals
• Find yours at: shiphelp.org

Medicare Rights Center:

• Helpline: 1-800-333-4114
• Free information and assistance

Center for Medicare Advocacy:

• Legal assistance for complex cases
• Educational resources

When to Consider Professional Help

You might benefit from a representative if:

• Your case involves significant money
• You’ve been denied multiple times
• Complex medical or legal issues exist
• You’re uncomfortable navigating the process

Options include:

• Healthcare attorneys
• Patient advocates
• Some doctors’ offices have billing specialists who help

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Timeline and Deadlines Checklist

After Receiving a Denial

Day	Action
1-3	Review denial notice carefully, note deadline
1-7	Contact doctor’s office about supporting documentation
7-14	Gather all medical records and evidence
14-21	Draft appeal letter
21-30	Have doctor review/sign letter of medical necessity
30-45	Submit appeal (well before deadline)
Ongoing	Track status, follow up as needed

Key Deadlines to Remember

• Level 1: 120 days from MSN date
• Level 2: 180 days from Level 1 decision
• Level 3: 60 days from Level 2 decision
• Level 4: 60 days from Level 3 decision
• Level 5: 60 days from Level 4 decision

Never miss a deadline—it can end your appeal rights.

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Common Mistakes to Avoid

In Your Appeal

❌ Missing the deadline ❌ Not addressing the specific denial reason ❌ Submitting without medical documentation ❌ Using emotional arguments instead of medical facts ❌ Giving up after Level 1 denial

With Documentation

❌ Incomplete medical records ❌ No letter of medical necessity ❌ Missing evidence of failed conservative treatment ❌ Wrong diagnosis codes ❌ Not keeping copies of everything

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Success Stories

Case 1: HA Injection Initially Denied

Denial reason: “Not medically necessary” Resolution: Level 1 redetermination succeeded after submitting:

• X-ray reports showing joint space narrowing
• PT records documenting 8 weeks of therapy without relief
• Doctor’s letter explaining treatment rationale

Case 2: Medicare Advantage Prior Auth Denied

Denial reason: “Step therapy requirement not met” Resolution: Level 2 (IRE) overturned after proving:

• Patient had documented allergies to required first-line medications
• Medical exception should have been granted
• Guidelines allow exceptions for documented intolerance

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Quick Reference: Appeal Checklist

Before Filing

• Received written denial notice
• Understood exact reason for denial
• Noted deadline for appeal
• Contacted doctor’s office for support
• Gathered all relevant medical records

Your Appeal Package

• Completed appropriate appeal form
• Written appeal letter addressing denial reason
• Copy of denial notice
• Relevant medical records
• Doctor’s letter of medical necessity
• Supporting research/guidelines (if applicable)
• Copies of everything for your records

After Submitting

• Sent via certified mail with return receipt
• Noted confirmation/tracking number
• Calendared expected decision date
• Planned follow-up if no response
• Prepared for next level if needed

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Related Resources

• Medicare Coverage Checklist
• Understanding Medicare Part B
• Prior Authorization Explained
• Medicare Coverage Guide