Medicare Denials and Appeals: What Families Need to Know

What Is a Medicare Denial?

A denial means Medicare, a Medicare Advantage plan or a Medicare drug plan has decided not to cover or pay for a service, item, drug or level of care.

Denials may involve:

• Skilled nursing facility rehab
• Home health services
• Hospital discharge timing
• Observation status issues
• Durable medical equipment
• Prescription drugs
• Prior authorization
• Out-of-network care
• Coverage ending sooner than the family expected

Appeal vs Complaint

These are not the same thing.

Appeal

Use an appeal when you disagree with a coverage or payment decision.

Complaint or Grievance

Use a complaint when the issue is service quality, access, delays, customer service or facility conditions.

Medicare explains that appeals apply when someone disagrees with a coverage or payment decision, while complaints are used for other problems such as plan service issues or facility concerns. :contentReference[oaicite:1]{index=1}

Common Medicare Denials Families Run Into

• Rehab coverage ending because the person is “not improving”
• Skilled nursing coverage denied after observation status
• Home health ending sooner than expected
• Therapy denied or reduced
• Durable medical equipment denied
• Medication not on the drug plan formulary
• Prior authorization denied under Medicare Advantage
• Out-of-network care denied
• Care labeled “custodial” instead of “skilled”

Related guides:

• Medicare Rehab Coverage
• Medicare Observation Status Explained
• Medicare and Home Health Care

Fast Appeals When Care Is Ending Too Soon

Fast appeal rights may apply when covered services are ending too soon from a hospital, skilled nursing facility, home health agency, hospice or comprehensive outpatient rehabilitation facility. :contentReference[oaicite:2]{index=2}

Ask immediately:

• What notice did we receive?
• What is the appeal deadline?
• Who is the BFCC-QIO or review organization listed on the notice?
• Can we request a fast appeal?
• What happens financially while the appeal is pending?

Original Medicare Appeals

For Original Medicare, the first level of appeal is generally called a redetermination. Medicare says the Medicare Summary Notice or denial instructions explain how to request review. :contentReference[oaicite:3]{index=3}

Gather:

• Medicare Summary Notice
• Denial letter
• Medical records
• Doctor letter explaining medical necessity
• Therapy notes or care records
• Discharge documents
• Any supporting timeline

Medicare Advantage Appeals

Medicare Advantage coverage decisions are called organization determinations, and appeals generally start with the plan. Medicare says Medicare Advantage appeals also have multiple levels if someone disagrees with the decision. :contentReference[oaicite:4]{index=4}

Ask the plan:

• Was this denied because of medical necessity?
• Was prior authorization missing?
• Was the provider out of network?
• Was the facility not contracted?
• Was documentation incomplete?
• What is the appeal deadline?
• Can this be expedited?

Prescription Drug Denials

Drug plan denials may involve formulary rules, prior authorization, step therapy, quantity limits or exception requests. Medicare notes that a prescriber may need to provide a medical reason for an exception. :contentReference[oaicite:5]{index=5}

Ask:

• Is the drug on the formulary?
• Does it require prior authorization?
• Is step therapy required?
• Is there a quantity limit?
• Can the doctor request an exception?
• Is there a covered alternative?

Observation Status Appeals

Observation status can create financial chaos when families expected skilled nursing rehab coverage. Medicare now recognizes appeal rights in certain situations when a hospital changes status from inpatient to outpatient observation. :contentReference[oaicite:6]{index=6}

Related guide: Medicare Observation Status Explained

What to Gather Before Filing an Appeal

• The denial notice
• The Medicare Summary Notice, if applicable
• Plan letters or authorization notices
• Doctor orders
• Medical records
• Therapy notes
• Medication records
• Discharge summary
• Facility notes
• Photos or documentation of safety concerns, if relevant
• Timeline of events
• Names and dates of phone calls

Related guide: How to Document Elder Care Concerns

What to Say When You Call

Then write down:

• Date and time of call
• Who you spoke with
• Reference number
• What they said
• Next step
• Deadline

Related Medicare & Caregiving Guides

Need Help Reading the Denial?

Medicare denial letters are not written for exhausted families. But the deadline, reason and next step are usually in there somewhere. Start with those three things.