Medicare Advantage Appeal Process: Step-by-Step When Your Parent's Plan Denies Care

Your parent's Medicare Advantage plan just denied prior authorization for home health visits. The denial letter says the services are "not medically necessary." You're looking at a parent who can't get out of bed without help, and a plan that says they don't need a nurse. The denial is almost certainly wrong — and the data proves it.

A June 2026 OIG investigation found that when families appealed prior authorization denials for skilled nursing facility admissions, Medicare Advantage plans overturned their own initial denial 95% of the time. The problem isn't that plans make careful clinical determinations — it's that most families never appeal. Only 18% of those SNF denials were appealed.

Level 1: Internal Reconsideration

Start here. Call the member services number on your parent's Medicare card and request a formal reconsideration of the denial.

Standard timeline: The plan generally must issue a decision within 30 calendar days for a standard pre-service appeal. The 7-calendar-day CMS-0057-F deadline applies to certain prior-authorization decisions, not this Level 1 appeal.

Expedited timeline: If a physician (your parent's doctor, not the plan's reviewer) certifies that waiting the standard period could seriously jeopardize your parent's life, health, or ability to regain maximum function, the plan must decide within 72 hours. Always request expedited review for home health and SNF denials — the physician certification language matters, so ask the doctor's office to state explicitly that delay could cause harm.

What to include: The denial letter, a brief statement of why you disagree, and any supporting clinical documentation. The physician's progress notes, therapy evaluations, or hospital discharge summary showing the need for skilled services carry the most weight.

If the plan overturns its decision at Level 1, services begin or resume. In the OIG's SNF sample, 95% of appealed denials were overturned at this level.

Level 2: Independent Review Entity (IRE)

If the plan upholds its denial at Level 1, it must automatically forward your case file to the Independent Review Entity for an independent reconsideration. As of May 2026, the IRE contractor is C2C Innovative Solutions, Inc.

You don't need to file anything separately — the plan is required to send the case and notify you. The IRE reviews the clinical evidence independently, without deference to the plan's medical director. Standard decisions come within 30 days; expedited within 72 hours.

Level 3: Administrative Law Judge (ALJ)

If the IRE upholds the denial, you can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals. There's a threshold: the Amount in Controversy must be at least $200 in 2026.

For home health denials, this threshold is usually met quickly — a single 60-day home health certification period is worth thousands of dollars in services. Calculate the AIC as: amount charged minus Medicare payments already awarded, minus applicable deductibles and coinsurance.

The ALJ hearing can be conducted by phone or video. You can represent yourself or bring an advocate. The hearing is your first opportunity to present evidence directly and question the plan's rationale in real time.

Level 4: Medicare Appeals Council

If the ALJ rules against you, the next step is review by the Medicare Appeals Council. This is a paper review — no hearing. The Council examines whether the ALJ applied the correct legal standards and whether the evidence supports the decision.

Level 5: Federal District Court

The final level requires an Amount in Controversy of at least $1,960 in 2026. Most home health disputes don't reach federal court, but the option exists for cases involving extended coverage denials with high financial exposure.

Practical Tips That Matter

Request continuation of benefits. If you appeal while services are still active, you can request that the plan continue coverage during the appeal. The plan must maintain services at the pre-denial level until the appeal is resolved. If you lose, you may be responsible for the cost of services provided during the appeal — but most families find this risk acceptable compared to a gap in care.

Get the physician involved. A one-sentence letter from your parent's doctor stating that the services are medically necessary carries significant weight at every level. Plans respond differently when the treating physician actively supports the appeal versus when the family files alone.

Keep every document. Save the original denial letter, your appeal request (with the date you submitted it), any correspondence from the plan, and the IRE decision. If you reach Level 3, the ALJ will want the complete paper trail.

The Medicare Home Health and Skilled Nursing Benefit guide includes appeal letter templates for each level, expedited review request scripts, and a tracking worksheet to ensure you don't miss a deadline.

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