Medicare Denial Appeals: How to Fight Back and Win
Medicare denied coverage. Now what? Whether it's a hospital stay, skilled nursing facility, home health, or medical equipment—don't give up. Medicare denials can be appealed, and a significant percentage of appeals succeed. Here's how to fight back.
Many people don't know they can appeal, or they assume it's hopeless. In reality, approximately 40-50% of Medicare appeals are successful at some level. The denial isn't always the final answer.
Common Medicare Denials
Hospital and Post-Acute Care
- Observation status instead of inpatient: Affects SNF coverage
- SNF stay not covered: "Not medically necessary"
- Home health denied: "Not homebound" or "not skilled care"
- Rehab days cut short: "No longer making progress"
Medical Equipment and Services
- Durable medical equipment (DME): Wheelchairs, hospital beds, oxygen
- Prescription drugs: Part D denials
- Procedures and tests: "Not medically necessary"
- Ambulance transport: "Not an emergency"
You have 120 days from the date of the Medicare Summary Notice (MSN) to file a Level 1 appeal. For some fast-track appeals (like ongoing care being cut), you may have only 2 days. Don't delay.
The 5 Levels of Medicare Appeals
Level 1: Redetermination
Who decides: Medicare Administrative Contractor (MAC)
Deadline: 120 days from MSN date
Decision time: 60 days (30 days for Part D)
How to file: Written request to the MAC listed on your denial notice. Include why you disagree and any supporting documentation.
Level 2: Reconsideration
Who decides: Qualified Independent Contractor (QIC)
Deadline: 180 days from Level 1 decision
Decision time: 60 days (7 days for Part D)
How to file: Follow instructions on Level 1 decision. A fresh set of eyes reviews your case.
Level 3: Administrative Law Judge (ALJ) Hearing
Who decides: Administrative Law Judge
Deadline: 60 days from Level 2 decision
Minimum amount: Must meet threshold ($195 in 2026)
Decision time: 90 days
How to file: Request a hearing. You can present evidence, testimony, and have representation.
Level 4: Medicare Appeals Council
Who decides: Department of Health and Human Services
Deadline: 60 days from ALJ decision
Decision time: 90 days
How to file: Written request to the Appeals Council.
Level 5: Federal Court
Who decides: Federal District Court
Deadline: 60 days from Level 4 decision
Minimum amount: Must meet threshold ($1,960 in 2026)
Note: Rarely needed. Most cases resolve at earlier levels.
Step-by-Step: Filing Your Appeal
Step 1: Read the Denial Carefully
- Understand exactly why it was denied
- Note the deadline for appeal
- Find the address/method for filing
- Check if it's an initial denial or a later level
Step 2: Gather Documentation
- Medical records supporting necessity
- Doctor's statement explaining why care is needed
- Lab results, imaging, test results
- Notes from therapists showing progress/need
- Personal statement describing impact on patient
Step 3: Write Your Appeal Letter
Include:
- Your parent's name and Medicare number
- Claim number being appealed
- Clear statement that you're requesting an appeal
- Specific reasons why the denial is wrong
- Reference to Medicare coverage rules that support you
- List of enclosed supporting documents
A letter from your parent's doctor explaining why the care is medically necessary is often the most important piece of an appeal. Ask the doctor to write a detailed letter referencing specific medical criteria.
Step 4: Submit and Track
- Keep copies of everything you send
- Send by certified mail or get confirmation
- Note the date you sent it
- Follow up if you don't hear back
Fast-Track Appeals (Expedited)
If your parent is being discharged from a hospital, SNF, or home health and you think it's too soon, you can request a fast-track appeal (called an "immediate review"). You must act within 2 days of receiving the discharge notice.
How to Request Fast-Track Appeal
- Ask for a written notice of the discharge or service termination
- Call the Quality Improvement Organization (QIO) for your state
- The QIO number should be on the discharge notice
- Request an expedited review within the deadline
- Your parent can stay while the review is pending
Common Denial Reasons and How to Counter
"Not Medically Necessary"
- Get a detailed letter from the doctor
- Provide documentation of the condition
- Show what would happen without the care
- Reference Medicare coverage criteria
"Not Homebound" (for Home Health)
- Document why leaving home is a taxing effort
- Note need for assistance to leave
- List medical reasons for staying home
- "Homebound" doesn't mean can never leave—occasional outings are allowed
"No Longer Making Progress" (for Therapy)
- Get therapist documentation of continued need
- Show that skilled care is needed to maintain function
- Note that maintenance therapy can be covered
- Document what would happen if therapy stopped
"Observation Status" (Hospital Stay)
- This is harder to appeal after the fact
- Ask about changing status while still in hospital
- If SNF is denied because of observation status, appeal the SNF denial
- Document why inpatient care was needed
Getting Help with Appeals
Free Help Available
- State Health Insurance Assistance Program (SHIP): Free Medicare counseling
- Hospital patient advocates: Can help with hospital-related denials
- Social workers: At hospitals, SNFs, home health agencies
- Legal aid organizations: For complex cases
- Center for Medicare Advocacy: National nonprofit that helps with appeals
When to Hire Help
Consider professional help for:
- Large dollar amounts at stake
- Complex medical issues
- Appeals that have already been denied multiple times
- Level 3 (ALJ) and beyond
- Don't give up after the first denial
- Include more documentation at each level
- Get doctors to write detailed letters
- Reference specific Medicare rules and criteria
- Keep copies of everything
- Meet all deadlines
While You Appeal
What Happens During the Appeal?
- You may need to pay out of pocket initially
- Keep all receipts and documentation
- If you win, Medicare will reimburse
- For ongoing services, request continuation during appeal
If Your Appeal Is Denied
- You can appeal to the next level
- Get additional documentation for the next level
- Consider getting professional help
- Some cases are stronger at higher levels (especially ALJ)
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