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
Got a medicare denial?
Free 24-hour review. Send the denial letter and we'll tell you whether your case has a shot and what the next step would look like.
Start my appealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.