Medicare Denied Your Maternity / Pregnancy Care?
Centers for Medicare & Medicaid Services (CMS) denies 18% of claims on average. But 75% of appeals succeed when patients fight back. Your maternity / pregnancy care denial may have grounds for a successful appeal.
Why Medicare Denies Maternity / Pregnancy Care
Services deemed not medically necessary (e.g., genetic testing)
Out-of-network delivery provider
Prior authorization not obtained for specialized maternity care
Medicare's Common Denial Tactics
Denying claims as not reasonable and necessary
Coverage determinations based on LCD/NCD criteria
Denying skilled nursing facility stays as custodial care
How to Win Your Maternity / Pregnancy Care Appeal
OB-GYN letter explaining medical necessity
Documentation of high-risk pregnancy factors
ACOG guidelines supporting the specific care
Laws That Protect You
ACA — Maternity and newborn care as Essential Health Benefits
Newborns and Mothers Health Protection Act (NMHPA)
Women's Health and Cancer Rights Act
Tips for Appealing to Medicare
Medicare has a 5-level appeal process — most denials are overturned by level 2 or 3
Request an ALJ hearing if redetermination and reconsideration fail
Cite specific LCD/NCD criteria and explain how your case meets them
Ready to Fight Your Maternity / Pregnancy Care Denial?
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This information is for educational and informational purposes only. It does not constitute legal or medical advice. Statistics cited are from publicly available sources including KFF, HHS OIG, and state insurance department data. Individual results may vary. Consult a qualified professional before taking action on your specific situation.