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Expert Q&A

How do I request an appeal be sent for external review for a Medicare Advantage plan? We’ve exhausted internal appeal levels for a medical necessity denial of inpatient hospitalization level of care. The state insurance commission told me they do not handle Medicare advantage plans. The CMS website states the payor is supposed to submit claims to IRO if denials are upheld, but I don’t think this is happening.

March 27, 2025 · Anna McGraw

The answer depends on whether you are contracted with the plan and how you filed your internal appeals.

  1. If you are contracted with the plan and you appealed on behalf of the provider (hospital), you are allowed whatever internal levels of appeal are provided in your contract and that’s all. The appeal never goes to CMS. External appeal is not available unless it is provided in your contract. The state insurance commission is not involved because Medicare and Medicare Advantage plans are under a federal program.
  2. If you are contracted with the plan and you appeal on behalf of the patient using the patient’s appeal rights, the MA plan must automatically forward your appeal to the IRO if the plan upheld your level 1 appeal.
  3. If you are not contracted with the plan and you appeal on behalf of the provider (hospital), the MA plan must automatically forward your appeal to the IRO if the plan upheld your level 1 appeal.

Answered by Denise Wilson MS, RN, RRT, Senior Vice President Intersect Healthcare + AppealMasters, President, AHDAM

Related

My hospital system is seeing an increase in denials from a multitude of payers (but mostly Humana and Aetna via third parties) where the payer has performed a clinical validation audit and found “the medical records submitted did not validate I50.00 (Acute on Chronic Diastolic (Congestive) Heart Failure). The member presented to the hospital for TAVR. It was noted the physician documented a diagnosis of acute on chronic diastolic CHF, however there was no evidence of symptoms. The specific criteria for Modified Framingham criteria was not met….” The payers are downgrading the billed DRG from 266 to 267. We are appealing these denials with the full medical record and outlining the physician’s diagnosis from the records; sometimes submitting past cardiology progress notes to support the diagnosis. Can AHDAM provide any additional tips, policies or insight into these denials and how to approach them for payment?
Expert Q&A

My hospital system is seeing an increase in denials from a multitude of payers (but mostly Humana and Aetna via third parties) where the payer has performed a clinical validation audit and found “the medical records submitted did not validate I50.00 (Acute on Chronic Diastolic (Congestive) Heart Failure). The member presented to the hospital for TAVR. It was noted the physician documented a diagnosis of acute on chronic diastolic CHF, however there was no evidence of symptoms. The specific criteria for Modified Framingham criteria was not met….” The payers are downgrading the billed DRG from 266 to 267. We are appealing these denials with the full medical record and outlining the physician’s diagnosis from the records; sometimes submitting past cardiology progress notes to support the diagnosis. Can AHDAM provide any additional tips, policies or insight into these denials and how to approach them for payment?

Mar 27, 2025