Medicare denials
Medicare denials follow a federally-defined 5-level appeal process. Most beneficiaries stop at level 1. The higher levels — particularly the Independent Review Entity and ALJ — reverse a meaningful share of cases.
What gets denied
- Skilled nursing facility (SNF) coverage
- Home health services
- Durable medical equipment (hospital beds, oxygen, mobility)
- Hospice eligibility
- Inpatient vs. observation status
- Part D drug coverage (separate ladder)
Common denial reasons
- Plan claims criteria for SNF / home-health not met
- DME deemed 'not medically necessary' or 'convenience'
- Inpatient stay reclassified as observation (lower coverage)
- Drug not on plan formulary or step therapy required
How we approach the appeal
File at level 1 within 60 days. Begin level-2 paperwork immediately on receipt of level-1 denial. The ALJ level (level 3) is where the most complex reversals happen — Medicare provides a federal judge to hear the case by phone.
60 days between each appeal level. Level-3 ALJ requires the case value to exceed $190 (2026) — multiple denials can be consolidated to meet this threshold.
$1,000 – $100,000+
- · Denial / determination letter
- · Medicare card
- · CMS-1696 Appointment of Representative form (we provide)
- · Treating physician's records
- · Care plan or facility records
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Start Your AppealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.