Submitting Medicare appeals is never at the top of anyone’s list of favorite things to do. It is, however, an essential tool in your revenue cycle toolkit so you can collect for your denied claims.

Most practices find out eventually that Medicare appeals don’t apply to every situation. Discover three times you can’t submit one, and what you can do instead.

1. Services That Are Excluded by Law

If Medicare statutorily doesn’t cover a particular service, there’s no point in filing an appeal for a denied claim. Your appeal will be immediately kicked out of the system and you won’t collect. Services that are excluded from Medicare payment by law include:

• Annual physicals (other than the Welcome to Medicare exam)
• Cosmetic surgery without medical necessity
• Hearing aids
• Most routine vision care
• Routine dental care
• Service that took place outside of the U.S.

If you want to collect for these services, you must collect directly from the patient. Although an advanced beneficiary notice (ABN) isn’t required for these types of services, it’s a good practice to have patients sign them for non-covered services. That way you have the patient’s signature noting what they’ve agreed to pay for the service and that they understand they won’t be able to collect for it.

2. Retroactive Eligibility

If the patient files for Medicare benefits more than six months after they turn 65, they may be eligible for six months of retroactive coverage — but no more than that. For instance, if a patient turned 65 on July 5, 2023 but didn’t file for benefits until July 5, 2025, they would only be eligible for retroactive benefits from January 5, 2025 on. Claims for any dates of service prior to that would be denied, and Medicare won’t accept an appeal.

If that’s the case with your claim, you should bill the patient’s previous insurer rather than appealing to Medicare. Find out who handled their medical insurance before they signed up for Medicare, and submit claims to that payer.

3. The Person Handling Medicare Appeals Isn’t Authorized

Medicare claims can only be filed by people with a financial interest in the claim. This includes the patient, their appointed or legal representatives, providers, and suppliers.

If you don’t have a financial interest in the patient’s claim, you cannot file an appeal. Instead, you may be able to help the patient or the medical practice create the appeal letter. But they’d have to submit it independently.