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  Medicaid Appeals

email: reimburse@cochlear.org




Appealing Medicaid Denials for Cochlear Implant Services



Otologic Reimbursement Management (ORM) was a pioneer in the area of reversing cochlear implant denials by State Medicaid programs and donated their services to assist numerous Medicaid beneficiaries in their fights against Medicaid programs that refused to comply with Federal rules and regulations requiring coverage of cochlear implant services. This includes personally representing them in administrative hearings.

Documents furnished by ORM from these appeals are too lengthy to be posted on this website. However, ORM has graciously agreed to provide the following summary of requirements for appealing Medicaid denials of cochlear implant services:

1. Most States will generally deny cochlear implant services because of the significant cost. Even though they know they the denial will be reversed, they will force the beneficiary to have to go through the appeal process to obtain benefits. Therefore a beneficiary should always appeal any denial related to cochlear implants.

2. Every State must "comply fully" with Federal laws and regulations. Substantial compliance is not sufficient, per the Ninth Circuit Court of Appeals. Very often, States are not in full compliance, so keep copies of all correspondence with Medicaid and do not accept any information over the phone without getting it in writing. Administrative hearing officers will frequently rule that the failure of the State to comply with even one Federal requirement is grounds for overturning a denial.

3. Most requirements for appeals of Medicaid denials are found at 42 CFR, Subpart E or Section 2902 of the State Medicaid Manual.

4. Unlike Medicare, Medicaid programs require a prior authorization request from the physician. All Medicaid programs are required to issue the beneficiary a written denial within 30 days of the prior authorization request explaining the basis for the determination and procedures to appeal. If the State does not respond in writing within 30 days, the request for prior authorization is automatically approved by default.

5. Failure of the denial notice to explain the denial or give adequate instructions to the beneficiary can void the denial of services. Medicaid cannot claim that the beneficiary should have read the Medicaid handbook or otherwise been aware of Medicaid requirements.

6. The beneficiary must appeal the denial in writing within a reasonable period of time, not to exceed 90 days. Most States set this at 30 days. It is not necessary to state the reason why the denial is appealed. However, it is important to send the letter certified mail to show the date Medicaid received it, as that starts the clock for the appeal.

7. If the beneficiary appeals the denial, the State must grant the beneficiary an administrative hearing who has been denied services. The hearing must consider whether the State’s action complies with Federal law. See 42 U.S.C. §1396a(a)(3) and 42 CFR §431.220.

8. These requirements do not change just because the beneficiary is enrolled in a Medicaid managed care plan. All the traditional Medicaid requirements apply to Medicaid managed care. Courts have consistently ruled that a State may not avoid its Federal obligations by contracting with private health plans.

9. Federal law and regulations clearly state that once the beneficiary has submitted an appeal notice, the State must take final administrative action within 90 days. See 42 CFR §431.244(f) and the State Medicaid Manual §2903.3. This is a prominent source of abuse by Medicaid programs, which frequently like to draw out appeals for a year or more.
These rules grant the State only a 30-day extension of this deadline for good cause, such as the need for additional "medical evidence". There is not provision for any longer delay. By that time, the State must not only have held an administrative hearing, but the Medicaid Director must approve or reject the finding of the hearing officer and issue notice to the beneficiary.

10. States cannot disregard the medical necessity opinion of the physician in order to avoid its obligation to provide Medicaid benefits that are in the "best interests" of the beneficiary. See 42 USC §1396a(a)(19).

11. Medicaid administrative hearings are very informal. Beneficiaries do not need to be represented by counsel, and generally speaking Medicaid will not have counsel present if the beneficiary is not represented by counsel. The Medicaid program should provide contact information for local pro bono counsel (or disability law centers) on the denial notice. These counsel are often unfamiliar with cochlear implant issues, but are usually contracted by the State and very familiar with the local administrative hearing procedures and hearing officers.

12. Traditional court rules of procedure are followed but the hearing officer will frequently allow both sides to enter whatever they wish into the record.

13. The ruling of the hearing officer (hired by the State) is limited to whether or not Medicaid complied with Federal and State rules and regulation in denying services.

14. The appeal process does not end with the ruling of the hearing officer. The Medicaid Director must approve or reject the ruling before it becomes official. If the denial is upheld, the only recourse of the beneficiary is to appeal to a court of law. However, nearly all Medicaid cochlear implant denials are overturned by the hearing officer, if not beforehand.