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

Question

Scott Sims · Accepted 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.

Tasha Riggs · 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

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

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.

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.

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.

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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