Please complete the form below and select Submit to send your request. The information will be sent securely to protect your privacy. Use the web browser print function if you would like to print a copy of this request for your records.

Please provide the following information if you are making a request on behalf of the member named above. To make this request, you must be the member’s representative and MVP must have an authorization on file. If we do not have this authorization, please send a completed Authorization of Representation Form CMS-1696 or a written equivalent. For more information on appointing a representative, call the MVP Medicare Customer Care Center or 1-800-MEDICARE.

Download PDF of Coverage Determination Request Form.

Note: Submitted requests may require a supporting statement from your prescriber.