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

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.

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.

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.

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

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

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.

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.

Bob 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.

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.