Appealing a Medicare denial — the process that actually works

This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.

Your mother had shoulder surgery. She followed the physical therapy plan. She went to all her appointments. Then a letter arrives from Medicare saying it won't cover the physical therapy anymore. The service is "not medically necessary," the letter says. Your mother needs six more weeks of therapy. Your family can't afford to pay out of pocket. You read the letter three times, trying to understand what it means, wondering if there's a mistake.

Getting a denial from Medicare feels personal, like someone is saying your parent's care doesn't matter, or that the doctor who prescribed it doesn't know what they're doing. In reality, it's a much more mechanical process. Medicare denies claims every day for lots of reasons, some of them justified, some of them the result of coding errors or insufficient information. The important thing to know is that denial isn't final. Appealing is possible. And sometimes, appeals work.

The appeal process can feel overwhelming if you've never done it before. There are different levels of appeal. There are timeframes you have to meet. There's terminology that sounds like government jargon. But the process exists for a reason: to make sure Medicare isn't denying coverage that should have been approved. If you know how the system works and you're willing to push back, you can sometimes get Medicare to reverse its decision.

Why Medicare Says No: Common Denial Reasons

Medicare denies claims for a few main reasons. The most common is that the service is deemed "not medically necessary." This doesn't mean your parent doesn't need the service. It means Medicare's computer system or Medicare's medical reviewer thinks the service isn't standard for treating your parent's condition. Your mother's orthopedist ordered 12 weeks of physical therapy, but Medicare's guideline for your mother's diagnosis says eight weeks is typically enough. Medicare denies the claim for weeks nine through twelve.

Another common reason is that the provider isn't approved to provide that service under Medicare, or the provider isn't in your parent's network if they have Medicare Advantage. Your mother sees a wonderful physical therapist in private practice, but that therapist doesn't have a Medicare provider agreement. Medicare denies the claim even though the therapy itself would have been covered if it came from an approved provider.

Sometimes Medicare says your parent already reached a benefit limit. This can happen with physical therapy, occupational therapy, and speech therapy. Medicare has annual limits on how much of these services it will cover. If your parent reaches the limit, Medicare stops paying. In theory, your parent can appeal the limit and potentially get more coverage if the therapy is medically necessary and your parent isn't making progress. But the burden is on you to prove it.

Sometimes the denial is because the provider submitted the claim incorrectly. The provider used the wrong code. The provider listed the wrong diagnosis. The provider failed to include supporting documentation. These coding errors are annoying because the service might actually be covered, but the paperwork is wrong. Usually, the provider can fix the error and resubmit.

Sometimes Medicare denies because your parent wasn't supposed to be billed for the service. Maybe the service should have been covered as part of your parent's hospital stay. Maybe it should have been covered under a different Medicare benefit. The denial tells you something is wrong with how the billing is being handled, and you need to contact the provider to fix it.

How Denials Are Communicated: Reading the Notice

When Medicare denies a claim, you get an Explanation of Benefits, or EOB. The EOB might go to your parent or to you, depending on how your parent's account is set up. It might come as a paper letter or appear in your parent's online Medicare account. The EOB will have a lot of information, and it can be confusing to read.

The key information is: what service was denied, why was it denied, and what are your appeal rights. The EOB includes the reason code for the denial. The reason code might be something cryptic like "not medically necessary" or "services rendered outside of approved facility." The EOB explains in slightly more detail what that means.

The important part of the EOB is the date you have to appeal by. You usually have 120 days from the date of the letter to request an appeal. That sounds like plenty of time, but it's easy for the letter to sit in a pile and the deadline to pass. Mark the appeal deadline on your calendar immediately.

The EOB also tells you whether you can appeal yourself or whether your parent needs to authorize someone else to appeal on their behalf. If your parent has given you power of attorney or has signed a form allowing you to handle their Medicare appeals, you can appeal directly. If not, your parent needs to be the one requesting the appeal, or they need to authorize you in writing.

The EOB explains what you can do next. Usually it says you can request reconsideration or file a more formal appeal. Read this section carefully. This is where you find out whether you can take the next step and what you need to do.

Appeal Level 1: Redetermination

The first appeal level is called redetermination. You're asking Medicare, or the Medicare contractor processing the claim, to look at the claim again and reconsider. When you request redetermination, you're essentially saying: "I don't think you made the right decision. Please review it again."

To request redetermination, you contact the Medicare contractor for your state. The EOB tells you who that contractor is and how to contact them. You can call, mail a letter, or submit the request online, depending on the contractor. You usually have 90 days from the date of the EOB to request redetermination.

When you request redetermination, include any new information that might help Medicare see why the service should have been covered. Maybe your parent's doctor has written a letter explaining why your parent needed longer physical therapy. Maybe there's additional medical evidence that the service was medically necessary. Include copies of this new information with your redetermination request. This gives Medicare a reason to change its initial decision.

You don't have to include new information to request redetermination. You can just ask them to reconsider. But new information gives you a better chance of success.

If Medicare denies redetermination, you get another letter explaining why and telling you about appeal level two. Keep that letter. You'll need it if you appeal further.

Appeal Level 2: Reconsideration (Independent Review)

If Medicare denies redetermination, the next appeal level is reconsideration, also called independent review. You're asking an independent Medicare contractor, someone who wasn't part of the original decision, to review the claim and decide whether Medicare made the right call.

To request reconsideration, you have 180 days from the date of the redetermination denial letter. You contact a different Medicare contractor than the one who made the original decision. The original denial letter tells you who to contact.

At this level, you want to present your best argument. If your parent's doctor believes the service was medically necessary, have the doctor write a letter. If there's medical literature supporting the need for the service your parent received, include it. If your parent's condition is unusual or your parent made better progress with the therapy than expected, explain that.

The independent reviewer looks at everything: the original claim, the reason for denial, your request, and any new evidence you provided. The reviewer decides whether Medicare made the right call. If they agree with Medicare, you can appeal further. If they disagree, Medicare will pay the claim.

Appeal Levels 3-5: When You Need Professional Help

If the independent reviewer denies your appeal, you have a right to further appeals. These involve administrative review by an Administrative Law Judge, appeal to the Medicare Appeals Council, and finally appeal to federal court. These levels are for significant dollar amounts because they require legal expertise and take time.

At the administrative law judge level, you're presenting your case to a government judge who specializes in Medicare appeals. This is more formal than the earlier levels. The case is documented in writing. Both sides get to present evidence. The judge issues a decision.

For most families dealing with a denied service that costs a few hundred or even a few thousand dollars, pursuing appeals to the Administrative Law Judge level probably isn't worth it without help from a lawyer. The costs of legal representation might exceed what you're trying to recover.

However, if your parent was denied coverage for something expensive—like a stay in a skilled nursing facility, or months of home health care, or a major piece of medical equipment—the larger dollar amount might justify hiring a lawyer who specializes in Medicare appeals. Some lawyers work on contingency, meaning they get paid only if they win, and they get paid from the recovery.

Getting Help with Appeals: When To Call in Reinforcement

Before you hire a lawyer, contact your State Health Insurance Assistance Program, or SHIP. SHIP counselors provide free Medicare counseling and help with appeals. They're knowledgeable about Medicare, they understand how denials work, and they can help you through the appeals process. They won't represent you like a lawyer would, but they can help you understand your options and prepare your case.

SHIP counselors can explain why Medicare denied your claim, help you understand what documentation you need to appeal, and coach you through the appeal process. If you're not sure whether appealing makes sense, talk to a SHIP counselor. They can give you an honest assessment of whether you have a strong case.

Hospitals and other providers also often have patient advocates. If your parent received services at a hospital and the hospital's services were denied, ask to speak with the patient advocate. The advocate might help you appeal or might contact the insurance and billing departments to figure out what happened.

For larger dollar amounts or complex cases, consulting with a lawyer who specializes in Medicare appeals makes sense. Many of these lawyers offer free consultations, so you can describe your situation and get an opinion on whether appealing is likely to succeed. The lawyer will know current Medicare policy and will know whether similar cases have succeeded or failed.

Making Your Appeal Effective

When you appeal, be clear about what you're appealing. Are you appealing because the service was medically necessary and Medicare was wrong to deny it? Are you appealing because there's a coding error and the service should have been covered? Are you appealing because the guideline Medicare cited is outdated? Be specific about your argument.

Provide evidence if you have it. Medical evidence carries weight. If your parent's doctor wrote a detailed note about why your parent needed the service, that's evidence. If your parent showed unusual progress or your parent's condition is unusual, explain that. Evidence of medical necessity can change outcomes.

Be persistent. The appeal process is designed so that if you ask the right people to reconsider and you have a decent case, you have a reasonable chance of winning at one of the appeal levels. Many people appeal once and give up if the first appeal is denied. But the independent reviewer, at appeal level two, might have a different opinion than the original decision maker. Don't assume one denial is final.

Keep good records. Save every letter from Medicare. Save every document you submit with your appeal. Save every response. Keep the appeal deadline dates on your calendar. The appeal process works on paperwork and timeframes. If you lose documentation or miss a deadline, you lose your appeal rights.

Most importantly, remember that appealing a Medicare denial isn't adversarial, even though it might feel that way. You're asking Medicare to review a decision that might be wrong. You're asserting your parent's right to coverage. Appealing is appropriate when you believe Medicare made a mistake or didn't have complete information when making the decision.

How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you are concerned about a loved one's cognitive health or safety, consult with their healthcare provider or contact your local Area Agency on Aging for guidance and support.