You've been told that Medicare won't cover your home health care, skilled nursing facility stay, or durable medical equipment. Your doctor says you need it. Your family knows you need it. But the denial letter says otherwise. What do you do now?

The answer is: you appeal. And here's something that may surprise you — Medicare appeals are overturned more often than most people realize. According to data from the Centers for Medicare & Medicaid Services (CMS), a significant percentage of Medicare denials are reversed on appeal, particularly at the first and second levels. Yet most beneficiaries never file an appeal because the process seems intimidating or they don't know they have the right.

This guide walks you through every step of the Medicare appeals process for post-acute care denials, from understanding why your claim was denied to navigating all five levels of appeal. Armed with this knowledge, you can fight for the coverage you deserve.

In This Guide

Understanding Why Medicare Denies Post-Acute Care Claims
Your Right to Appeal: The Legal Framework
The Five Levels of Medicare Appeals
Fast-Track Appeals: The QIO Process
How to Write a Strong Appeal Letter
Getting Help with Your Appeal
Common Post-Acute Care Appeals Scenarios
Protecting Yourself During the Appeals Process
Preventing Future Denials
Related NDPAP Resources

Understanding Why Medicare Denies Post-Acute Care Claims

Before you can successfully appeal, you need to understand why your claim was denied. The most common reasons for post-acute care denials include:

Medical necessity not established. Medicare determined that the service wasn't medically necessary based on the documentation provided. This is the most common denial reason and often the easiest to overturn with better documentation from your doctor.

Eligibility criteria not met. For example, you didn't meet the homebound requirement for home health, or you didn't have a qualifying 3-day inpatient hospital stay for skilled nursing facility coverage.

Service not covered. Medicare determined that the specific service you received isn't a covered benefit under your plan.

Provider not enrolled or certified. The provider wasn't properly enrolled in Medicare or wasn't a contract supplier under the competitive bidding program.

Documentation errors. Missing signatures, incomplete forms, coding errors, or failure to meet documentation requirements like the face-to-face encounter.

Coverage terminated prematurely. Your home health, skilled nursing, or other services were ended before you believe they should have been.

Your denial notice — called a Medicare Summary Notice (MSN) for Original Medicare or an Explanation of Benefits (EOB) for Medicare Advantage plans — will include the specific reason for the denial and instructions for how to appeal.

Your Right to Appeal: The Legal Framework

The right to appeal Medicare decisions is protected by federal law. Under the Medicare appeals process established by CMS, you have the right to request a review of any coverage decision, receive a timely decision on your appeal, continue receiving services during certain appeals (without financial liability), be represented by someone you trust (a family member, friend, or attorney), and access all five levels of appeal if necessary.

These rights apply whether you have Original Medicare or a Medicare Advantage plan, though the specific procedures differ slightly.

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The Five Levels of Medicare Appeals

Level 1: Redetermination (Original Medicare) or Reconsideration (Medicare Advantage)

Timeline: You must file within 120 days of receiving your denial notice. For Medicare Advantage plans, the deadline is 60 days.

Who reviews it: For Original Medicare, the Medicare Administrative Contractor (MAC) that processed the original claim reviews the appeal. For Medicare Advantage plans, the plan itself conducts the review.

What to do: Write a clear appeal letter explaining why you believe the denial was wrong. Include any additional documentation from your doctor that supports medical necessity, specific references to Medicare coverage rules that support your case, a statement from your doctor explaining why the service is medically necessary, and any relevant medical records, test results, or clinical notes.

Success rate: This level has a reasonable success rate, particularly when denials were based on documentation issues that can be corrected.

How long it takes: Decisions are typically made within 60 days for Original Medicare.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

Timeline: You must file within 180 days of the Level 1 decision.

Who reviews it: An independent organization called a Qualified Independent Contractor (QIC) reviews the case. This is important because the QIC is completely independent from Medicare and the insurance company.

What to do: Submit your appeal to the QIC listed on your Level 1 decision letter. Include all documentation from Level 1 plus any new evidence.

Success rate: The QIC often reverses Level 1 denials because they take a fresh look at the case with independent medical expertise.

Level 3: Hearing by an Administrative Law Judge (ALJ)

Timeline: You must file within 60 days of the Level 2 decision. The amount in controversy must meet a minimum threshold (which changes annually — it was $180 in 2025).

Who reviews it: An Administrative Law Judge with the Office of Medicare Hearings and Appeals (OMHA) conducts a hearing, which may be in person, by video, or by telephone.

What to do: Prepare as you would for a court hearing. You can present evidence, call witnesses (including your doctor), and argue your case. Having legal representation at this stage can be very helpful.

Success rate: ALJ hearings have historically had high reversal rates for Medicare appeals.

Level 4: Review by the Medicare Appeals Council

Timeline: You must file within 60 days of the ALJ decision.

Who reviews it: The Medicare Appeals Council, which is part of the Department of Health and Human Services (HHS).

What to do: Submit a written request for review explaining why the ALJ's decision was incorrect. This is a paper review — there's typically no hearing.

Level 5: Federal District Court

Timeline: You must file within 60 days of the Appeals Council decision. The amount in controversy must meet a higher minimum threshold (which was $1,840 in 2025).

Who reviews it: A federal district court judge.

This final level is rarely needed for post-acute care denials, but it exists as a last resort.

Fast-Track Appeals: The QIO Process

For certain time-sensitive situations, there's a faster appeals process through your state's Quality Improvement Organization (QIO). You can use this expedited process when your home health agency, skilled nursing facility, or hospital tells you that Medicare coverage is ending, you're being discharged from a hospital and you believe it's too soon, or your Medicare Advantage plan denies authorization for a service you believe you need urgently.

The QIO process is critically important because it allows you to continue receiving services without financial liability while the appeal is pending — as long as you file before the coverage termination date stated in your notice.

To file a QIO appeal, call the QIO listed on your notice (or call 1-800-MEDICARE for the number) before the stated termination date, the QIO will review your case and make a decision within 24-72 hours, and if the QIO upholds the termination, you can then proceed through the standard appeals process.

📋 Understanding Your Care Options? Read: What Happens After the Hospital: A Step-by-Step Guide to Post-Acute Care

How to Write a Strong Appeal Letter

Your appeal letter is the foundation of your case. Here's how to write one that gives you the best chance of success:

Start with the basics. Include your name, Medicare number, claim number, date of service, and the specific service being denied.

State your case clearly. Explain in plain language why you believe Medicare should cover the service. Reference specific Medicare coverage criteria and explain how you meet them.

Include supporting documentation. Attach a letter from your doctor explaining the medical necessity of the service, relevant medical records and test results, any clinical guidelines or Medicare coverage rules that support your case, and a detailed care plan if applicable.

Be specific about the denial reason. Address the exact reason given for the denial. If Medicare says you're not homebound, provide specific evidence of why leaving home is a considerable effort. If they say the service isn't medically necessary, provide clinical evidence showing why it is.

Keep it factual and professional. While it's natural to be frustrated, stick to facts, medical evidence, and coverage rules rather than emotional arguments.

Getting Help with Your Appeal

You don't have to navigate the appeals process alone. Several resources are available to help:

State Health Insurance Assistance Program (SHIP). Every state has a SHIP program that provides free, unbiased counseling on Medicare issues, including appeals. SHIP counselors can help you understand your denial, gather documentation, and file your appeal. Find your local SHIP at shiphelp.org.

Medicare Rights Center. The Medicare Rights Center operates a national helpline (1-800-333-4114) that provides free assistance with Medicare problems and appeals.

Elder law attorneys. For complex cases or higher-dollar claims, an elder law attorney can provide legal representation. Many offer free initial consultations. The National Academy of Elder Law Attorneys (NAELA) can help you find an attorney in your area.

Your provider. Your home health agency, skilled nursing facility, or DME supplier may have staff experienced in Medicare appeals and can help with documentation and filing.

Beneficiary and family advocacy organizations. Organizations like the Center for Medicare Advocacy provide resources, education, and legal assistance for Medicare beneficiaries.

Common Post-Acute Care Appeals Scenarios

Home Health Denial: "Not Homebound"

If Medicare denies your home health claim because you don't meet the homebound criteria, your appeal should document what specific condition makes leaving home a considerable effort, what assistance you need to leave home (wheelchair, walker, help of another person), that any outings are infrequent, short in duration, and/or for medical purposes, and a statement from your doctor confirming your homebound status.

SNF Denial: "No Longer Needs Skilled Care"

If your skilled nursing facility stay is being terminated because Medicare says you no longer need skilled care, your appeal should include documentation from your therapy team showing ongoing progress and rehabilitation potential, your doctor's statement about why continued skilled care is medically necessary, specific skilled services you're still receiving and why they require professional expertise, and evidence that premature discharge could lead to complications or readmission.

DME Denial: "Not Medically Necessary"

For durable medical equipment denials, your appeal should include a detailed prescription from your doctor explaining why the equipment is medically necessary, documentation of your medical condition and functional limitations, evidence that the equipment meets Medicare's DME definition, and any clinical guidelines recommending the equipment for your condition.

Protecting Yourself During the Appeals Process

While your appeal is pending, keep these important protections in mind. If you have Original Medicare and receive services while an appeal is pending, you may not be financially liable for the services if you filed a timely appeal. If you have a Medicare Advantage plan, the plan must continue to provide services during an expedited appeal if the services were previously authorized. Always request an Advance Beneficiary Notice (ABN) or Notice of Medicare Non-Coverage before agreeing to receive services that may not be covered. And keep copies of everything — every letter, notice, medical record, and communication related to your appeal.

Preventing Future Denials

While knowing how to appeal is important, preventing denials in the first place is even better. Work with your providers to ensure all documentation clearly supports medical necessity, all required paperwork (physician orders, face-to-face encounters, care plans) is completed and signed, services are provided by Medicare-enrolled and certified providers, prior authorization is obtained when required (especially for Medicare Advantage plans), and your care plan is updated and recertified on schedule.

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Understanding Medicare Coverage for Post-Acute Care — know what should be covered before you appeal
Does Medicare Cover Home Health Care? — understand home health eligibility
Does Medicare Cover Skilled Nursing Facility Care? — SNF coverage details
Medicare Coverage for Durable Medical Equipment — DME coverage rules
Medicare vs. Medicaid — understanding your coverage options

This article is for informational purposes only and does not constitute legal advice. Medicare rules and appeals processes can change. For the most current information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). For free help with Medicare appeals, contact your local State Health Insurance Assistance Program (SHIP) or the Medicare Rights Center at 1-800-333-4114.