I need home health care after my surgery, but Medicare denied coverage. What are my appeal rights?

Question

Tasha Riggs · Accepted Answer

My concern would be why did they deny it.
Home Health Care is a Skilled Nursing Code. 
Doctor has to certify that you are home bound and that you need a nurse to come in and do basic MEDICAL needs for you.  Example is wound care or Medicine care and PT.
They don't stay very long. They come in and do the medical care needed and leave. 
They would have to have a reason why you can come to them to get approved. 
It is also only approved for 30 days and can be extended if the doctor approves it. It has to be recertified every 60 days.  It is meant for short term and that you are healing and getting better. 
If you need it all the time and your not getting better then that will be under Long Term Care. That is a separate policy and not covered by Medicare.
If you want to file an appeal here is the link: 
https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals

Pamela Masters · Answer

If you have Original Medicare there are 5 levels of appeal. You start at one and once the determination is made if you need to you can go to level 2 and so on. If you go to Medicare.gov it will give you details about how to proceed.

Answered by Pamela Masters on November 30, 2025

Broker Licensed in NC

Answered by Pamela Masters Medicare Insurance Agent

Ellen Diehl · Answer

When you say Medicare denied to cover that do you mean original Medicare part B as in Boy?? Or do you mean your supplemental plan? Or do you mean your Advantage plan? If you can give me some more detail details, I can help you answer your question.

Answered by Ellen Diehl on May 18, 2026

Broker Licensed in GA

Answered by Ellen Diehl Medicare Insurance Agent

Lilyana Uzdenova-Gomez · Answer

Step 1: I would make sure that all of the qualifications for home healthcare are met: the person is homebound, daily skilled care is required, there is a realistic chance of improvement, you could not get that care on the outpatient basis, and the doctor Properly Certified the need. 
Step 2:  If all of the conditions are met, you have a great case for appealing that denial. You could simply take that case from a simple Redetermination and Reconsideration case by contacting Medicare all the way to Office of Medicare Hearings and above.

Paula Duffy · Answer

You will need to review your evidence of coverage for what your benefits cover.

After that please either contact member services or your agent to have them review what your options are and if there is an appeal address.

Scott Sims · Answer

You can always appeal. According to the Medicare Rights Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals result in coverage for the beneficiary.

Steven Bleicher · Answer

You actually have up to four appeals. The insurance company will ignore the first one but when you appeal a 2nd time, now they know that you are serious. Your doctor will have written up your “Plan of Care” which enumerates the number of days that she/he feels is best for you based on the severity of your condition. The appeals process is on the Medicare website and this process is about 3 days after submission. Should you be declined for all 4 appeals (doubtful), the next phase is the filing of a grievance again thru the same Medicare.gov website.

Answered by Steven Bleicher on June 4, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Andrew Zurbuch, MBA · Answer

Sorry, your claim was denied. Please call 1800Medicare regarding your claim. Make notes of whom you spoke with and the when. Read your Explanation Of Benefits you recieve from Medicare. Thank you.

Diana Garner · Answer

The notice you receive from Medicare, which includes details on why home health care was denied, will also include information regarding your appeal rights and the steps to take.

First, you must file an internal appeal (redetermination) with the Medicare Administrative Contractor, which involves submitting a request form with supporting documents. 

If the Medicare Administrative Contractor denies your coverage after reviewing, you may request reconsideration by a Qualified Independent Contractor. 

If denied again, you can request an Administrative Law Judge hearing. This involves a formal hearing in front of the Judge, and you will present evidence and argue your case. 

If the Judge denies your claim, you can appeal to the Medicare Appeals Council. 

If you are still unsatisfied, you may have the right to seek judicial review in the Federal District Court.

Timothy Brown · Answer

Question for you; Has your doctor submitted a physician certification form stating that home healthcare is necessary. If the answer is yes, then you can appeal withe decision.

Richard Kozlowski · Answer

Below is the link you will want to review

https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals

You will also find the information in your Medicare and You 2025 book

Rich Kozlowski
LifeSmart Senior Services

Arleda Lagrone-Pittman · Answer

A doctor is one of our greatest assets in your appeal rights. It is important that a doctor clarifies that your surgery is required for your quality of life. And possibly they might need to resubmit an appeal on your behalf. Make sure everything was coded properly to process the claim. And you can also file an appeal to Medicare

Answered by Arleda Lagrone-Pittman on January 26, 2026

Broker Licensed in NE

Answered by Arleda Lagrone-Pittman Medicare Insurance Agent

Vachik Chakhbazian · Answer

you have the right to appeal. The first step is a redetermination, where you submit a written request within 120 days of the initial denial. If that's denied, you can move on to a reconsideration, a level two appeal with a Qualified Independent Contractor.

Answered by Vachik Chakhbazian on April 26, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Gary Henderson · Answer

Did Medicare deny coverage or did your Medicare advantage plan deny covers? There is a big difference you've been turned over to an insurance company if you bought a Medicare advantage plan 
Coverage can vary from Aboriginal Medicare 
Yes, you can appeal any decision. They have to respond quickly by law 
If it was denied by Medicare itself, contact Medicare or go on to medicare.gov for information on how to file for an exception

Suzanne Lamperti · Answer

You have the right to appeal the decision within a certain period of time. Call Medicare and ask how to appeal the decision. They may approve it if it is medically necessary.

Mike Henry · Answer

Go to your Dr. see if they can help you. Make sure everything is coded correctly. Make sure the request for home health was requested properly

Dean Chiapetto · Answer

You can appel to Medicare. The agency you plan to use should beable to help with this if it is medically necessary.

Rodolfo Rojas · Answer

I would suggest that you first check if your doctor required that you get home care service. 
It needs to be provided by Medicarecertified agency. 
I don't know whether you have original Medicare or you have Medicare Advantage or a supplement, in which you would need to reach out to them. 
You should have gotten a summary notice of why your claim was denied. It should have an explanation of how to appeal their decision. You can use form 20027, Medicare Retermination Request. 
I would get documentation from your doctor stating that you need this type of care.

Sam Silva · Answer

Request a Reconsideration by contacting the company that handled your Medicare claim.

You can request reconsideration by calling Medicare or submitting a written appeal.

Provide any additional supporting documents that may support your case, such as your doctor’s orders or evidence of medical necessity.

you can request a review by the Medicare Appeals Council.

Ashley King · Answer

To start the appeal process, you first have 120 days from the time coverage was denied to file for a redetermination of coverage. I recommend you start by reaching out to your doctor to provide more details as to why home health care is medically necessary for you after surgery. If coverage is still denied you can move on to the next step of the appeals process which is for reconsideration and allows for an independent review which all details will be provided for that if redetermination is denied.

Answered by Ashley King on June 1, 2026

Broker Licensed in MD, AL, AR & 9 other states

Answered by Ashley King Medicare Insurance Agent

Robert Nunn · Answer

My advice is to go to Medicare.gov and download the 2025 Medicare and you book . In Section 8 page 97 -106 is a step by step guide to appeal and a lot of very useful information.

Wild Bill Anderson · Answer

You always have the right to appeal any denied benefit. Start by giving us a call so we can either escalate your appeal or we can direct you on who to reach out to.

Leisha Stevens · Answer

If Medicare denies coverage for home health care after surgery, you have the right to appeal the decision. You can file an appeal with Medicare, and if that's not successful, you can continue the appeals process through multiple levels. 
Here's a breakdown of the appeal process:
1. Initial Appeal (Level 1):
You can start by appealing the decision with your Medicare plan or, if you have Original Medicare, with the Medicare administrative contractor (MAC). 
2. Reconsideration (Level 2):
If the initial appeal is denied, you can request a reconsideration by a Qualified Independent Contractor (QIC). 
3. Independent Review Organization (IRO):
If the reconsideration is also denied, you may be able to request an external review by an independent review organization (IRO). 
4. Office of Medicare Hearings and Appeals (OMHA):
If you still disagree, you can request a hearing before the OMHA. 
5. Medicare Appeals Council:
If the OMHA decision is not favorable, you can request a review by the Medicare Appeals Council. 
6. Federal Court:
In certain circumstances, you may be able to take your case to Federal court for review. 
Important Considerations:
Deadlines:
There are specific deadlines for each level of appeal, so it's important to understand and follow those guidelines. 
Supporting Documentation:
You should gather any relevant medical records, documentation, and supporting evidence to support your appeal. 
Fast Appeal:
If the denial is urgent, you may be able to request a fast appeal. 
Helpful Resources:
You can find information and assistance through the Medicare website, the State Health Insurance Assistance Program (SHIP), and other organizations. 
In summary, if Medicare denies your home health care coverage, you have a right to appeal. Start with your plan or the MAC, and if necessary, proceed through the subsequent levels of the appeals process. Be sure to meet deadlines and gather any supporting documentation to strengthen your case.

Juan Carlos Quevedo Lussón · Answer

If Medicare denied your home health care coverage, you have the right to appeal that decision. The appeals process allows you to ask Medicare to review and reconsider its determination. You don’t lose your Medicare rights during an appeal, and help is available from State Health Insurance Assistance Programs (SHIP) or a licensed Medicare agent who can guide you through each step.

Answered by Juan Carlos Quevedo Lussón on October 22, 2025

Broker Licensed in TX

Answered by Juan Carlos Quevedo Lussón Medicare Insurance Agent

Bill Holland · Answer

You can always appeal a Medicare Denial of Coverage. You can generally find out how to appeal on pages 97-102 of the 2026 Medicare & You book.
If you do not have a copy, go to your local Social Security office. There is a form  CMS-20027. You can download that form.
Or call 1-800-MEDICARE  to get a copy mailed to you.

If you have a Medicare Advantage Plan or Medicare Prescription Plan, check the "Evidence of Coverage" you received from your Insurance Company

A Medical Professional must request Home Health Benefits.
A lot of the time, the denial is a matter of what the Doctor/provider said,
or what was not said, or what was not said clearly.
I had a personal problem getting some Durable Medical Equipment approved because of forms/prescriptions not being filled out correctly for the DME Provider and Medicare.
Finally, if you think the Denial is wrong, go to work quickly and find out why.

I need home health care after my surgery, but Medicare denied coverage. What are my appeal rights?

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I need home health care after my surgery, but Medicare denied coverage. What are my appeal rights?

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