Medicare Exceptions Explained: Requests & Appeals

Ever stared at a denial notice from your Medicare plan and thought, “There’s got to be a way around this?” You’re not alone. A Medicare exception is basically a special request that lets you get a drug or service that would otherwise be blocked or cost more under your plan. In this post, I’ll walk you through exactly what counts as an exception, who can ask for one, how to put together a winning request, and what to do if the plan says “no.” By the end, you’ll have a clear roadmap and the confidence to advocate for the care you deserve.

What Are Exceptions?

Definition straight from CMS

According to the Centers for Medicare & Medicaid Services (CMS), “an exception request is a type of coverage determination.” In plain English, it’s a formal ask to the plan to bend the usual rules because the standard coverage won’t meet a specific medical need.

Main categories

Tiering exception

This one is all about cost‑sharing. If a drug sits in a higher‑cost tier (think brand‑name specialty) but you need it because the lower‑tier alternatives either don’t work or cause side effects, you can request to pay the lower‑tier amount.

Formulary exception

When a medication isn’t on your plan’s formulary—or you need a rule like prior authorization or step therapy waived—you can file a formulary exception. The goal is to get the drug covered despite it being “off‑list.”

Small‑Employer Exception (SEE)

For folks whose employer has fewer than 20 employees and is part of a multi‑employer Group Health Plan, a Small‑Employer Exception can be requested so Medicare becomes the primary payer. It’s a niche but important carve‑out.

Therapy‑cap exception (DRA)

Outpatient physical, occupational, or speech‑language therapy caps can be exceeded if a provider proves the extra services are medically necessary. The Deficit Reduction Act (DRA) sets up an “automatic” exception for certain conditions; otherwise, a manual request is required.

When an exception isn’t possible

Medicare won’t grant exceptions for services that are clearly not medically necessary, cosmetic procedures, or anything that falls outside the statutory limits. Knowing the line helps you focus your effort where it matters.

Who Can Request?

Eligible requestors

Three parties can pull the trigger:

• The enrollee (that’s you).
• Your prescribing clinician.

What the plan wants: a supporting statement

CMS is crystal clear: the prescriber must submit a supporting statement that explains why the requested drug or service is medically necessary. Here’s a quick checklist you can share with your doctor:

• Describe the medical condition and why the preferred alternative isn’t suitable.
• Detail any adverse effects the patient experienced with lower‑tier drugs.
• Explain dosage or quantity issues that make the requested drug essential.
• Reference any clinical guidelines or studies that back the choice.

How to send it

Written submission

The safest route is the Model Coverage Determination Request Form, available for download on the CMS “Exceptions” page. Attach the physician’s letter and any lab reports, then mail or fax it to the plan’s address.

Verbal submission

If you call the plan, a representative might accept the request verbally but will usually ask for written follow‑up. Make a note of the date, time, and the name of the person you spoke with—this will be valuable if you need to appeal later.

Timeline expectations

CMS mandates that plans respond within:

• 24 hours for expedited benefit requests.
• 72 hours for standard benefit requests.
• 14 days for payment‑related exception requests.

If you don’t hear back within these windows, you can treat the silence as a denial and move straight into the appeal process.

Why Request Exceptions?

Non‑formulary drug needed

Imagine your oncologist prescribes a cutting‑edge medication that isn’t on your plan’s list. Without a formulary exception, you could face a massive out‑of‑pocket bill—or worse, no access at all. A successful request can bridge that gap.

Waiving utilization management

Step therapy or prior authorization can stall life‑saving treatment. If your doctor can demonstrate that the “step” would jeopardize your health, a formulary exception can lift the barrier.

Reducing cost‑sharing (tiering)

Sometimes the cheapest generic simply won’t work for you. A tiering exception can lock you into the lower co‑pay bracket even for a brand‑name drug.

Retroactive entitlement situations

Under 42 CFR 424.44(b), if you receive Medicare eligibility retroactively—say, after a hospital stay—you can still file an exception for services rendered before the official eligibility date.

Therapy‑cap overruns

After knee surgery, your physical therapist might recommend 30 sessions, but the cap limits you to 20. If the extra 10 are medically justified, you can request a therapy‑cap exception.

Balancing the benefits (better health outcomes, lower out‑of‑pocket costs) against the risks (potential higher plan costs, longer processing time) is key. That’s why a well‑documented request matters.

Appeal Process When Denied

First step: redetermination

When the plan says “no,” they must also send you a written coverage determination explaining why. Use that letter as your springboard. Submit a redetermination request (often called a “reconsideration”) within 60 days. Include any new medical evidence, a stronger physician letter, or even a peer‑review article that backs your case.

Escalating the appeal

If the redetermination is also denied, Medicare offers a five‑level appeal hierarchy:

1. Reconsideration (the redetermination you just filed).
2. Administrative Law Judge (ALJ) hearing.
3. Medicare Appeals Council review.
4. Federal Circuit Court of Appeals.
5. U.S. Supreme Court (only in rare cases).

Each level has its own deadlines, so keep a master spreadsheet with dates, contacts, and copies of every document you send.

Building a rock‑solid appeal

• Attach the original physician statement plus a supplemental letter that directly addresses the plan’s denial reason.
• Include any relevant clinical studies or guidelines—CMS often references National Comprehensive Cancer Network (NCCN) protocols for oncology drugs, for example.
• Highlight any “real‑world” impact: worsening symptoms, emergency room visits, or loss of function.
• Quote the plan’s own policy language when possible; showing they’re contradicting their own rules can be persuasive.

External resources

For a step‑by‑step walkthrough of the Medicare appeal process, the official Medicare website offers a clear guide according to Medicare.gov. It explains each appeal level, timelines, and what paperwork you’ll need.

Real‑World Cases (Experience in Action)

Case 1 – Tiering exception for an asthma inhaler

Mrs. Garcia, a 68‑year‑old with severe asthma, was prescribed a brand‑name inhaler that wasn’t on her plan’s formulary. Her doctor submitted a tiering exception stating that the generic caused bronchospasm. The plan responded within 48 hours and approved the request, saving her $150 per month.

Case 2 – Small‑Employer Exception for a rural clinic

A multi‑employer health plan covering several small farms wanted Medicare as the primary payer for employees of a 12‑person dairy. After gathering payroll records and a letter from the state health department, the plan’s Benefits Coordination & Recovery Center approved the SEE, allowing those employees to access Medicare‑covered services without gaps.

Case 3 – Therapy‑cap exception after knee surgery

John, a 72‑year‑old retired teacher, needed 30 physical‑therapy sessions post‑total knee replacement. The plan’s cap allowed only 20. His therapist filed a manual exception request, citing clinical notes that the extra 10 sessions were essential for achieving functional walking. The plan granted an automatic exception because the surgery qualified under “complex orthopedic procedures.” John’s out‑of‑pocket cost dropped from $1,200 to $0.

What we learned

• Clear, concise medical justification is king.
• Providing the plan’s own policy language can turn a denial into an approval.
• Timing matters—act quickly, especially with expedited requests.

Key Takeaways

Medicare exceptions are a powerful safety net when standard coverage falls short. By understanding the types of exceptions, who can file, the exact documentation needed, and the timelines that govern each step, you can move from feeling stuck to feeling empowered. If a request gets denied, remember the structured appeal process is there to protect your rights.

Ready to take the next step? Grab the CMS model request form, talk to your prescriber today, and keep a written record of every conversation. You have the right to the care you need—don’t let paperwork stand in your way.