What CaseWhy Appeals covers
Every Medicare appeal we handle: Medicare Advantage, Medicare Part D, Original Medicare, Medicare premiums and Extra Help, Medicare enrollment and entitlement, and PACE (Program of All-Inclusive Care for the Elderly). Below that, what's free but isn't technically an appeal, where we point you when we don't handle something directly, and what we don't do at all.
Medicare appeals we handle
Medicare Advantage
Start here →- Skilled nursing facility (SNF) level of care
- Inpatient rehabilitation facility (IRF) admission criteria
- Home health homebound status and skilled-need requirement
- Power mobility devices (wheelchairs, scooters)
- CPAP therapy for obstructive sleep apnea
- Home oxygen and oxygen equipment
- Inpatient admission vs. observation status (two-midnight rule)
- Part B drug coverage-determination timelines
- Imaging/procedure prior authorization (plan internal criteria)
- A previously authorized Medicare and/or Medicaid service is ending or being reduced (continuation of benefits)
- A Medicaid-covered long-term care or personal-care service, within a combined Medicare/Medicaid denial
- Billed for a Medicare cost-sharing amount Medicaid should have covered
Medicare Part D
Start here →- Drug not on the plan's formulary
- Tiering exception (cost-sharing tier)
- Prior authorization criteria not met
- Step therapy requirement not met
- Quantity limit exceeded
- Part B vs. Part D coverage determination
- Statutorily excluded drug
- Transition fill owed (new enrollee or formulary change)
- Paid out of pocket — reimbursement request
Original Medicare
Start here →- Skilled nursing facility (rehab) stay ending
- Home health services ending
- Hospice services ending
- Outpatient rehab (CORF) services ending
- Hospital discharge — too soon
- Changed from inpatient to observation (MCSN received)
- Reclassified to observation, but no MCSN given
- Observation stay before Feb 14, 2025 (retrospective window)
- SNF coverage denied for lack of a 3-day inpatient stay
- Denied as not reasonable and necessary
- Durable medical equipment denied (CPAP, oxygen, power mobility, hospital bed, diabetic supplies)
- Denied because the patient isn't improving (SNF, home health, or outpatient therapy)
- Home health denied — not homebound, or no face-to-face encounter
- SNF coverage denied for lack of a 3-day qualifying inpatient stay
- Outpatient therapy denied above the KX-modifier threshold
- Denied for exceeding a frequency limit (labs, imaging, preventive services)
- Ambulance transport denied as non-emergency
- A hospice-related service was billed to Medicare separately and denied
- The provider billed you after Medicare denied the service
- You signed an ABN, but it may not be valid
- The MSN shows a duplicate claim or a billing error — not really an appeal
- The demand includes claims that aren't related to the accident or injury
- The demand amount itself is calculated wrong
- You don't dispute the debt, but repaying it would cause real hardship
- Ask Medicare to accept less than the full amount
Medicare premiums and Extra Help
Start here →- A life-changing event lowered our income since the tax year SSA used
- SSA used a tax year that's older than necessary
- SSA used the wrong IRS income information
- We filed separately and lived apart all year, but SSA used the joint-filer table
- Extra Help denied
- Extra Help reduced or ended
- We had other drug coverage as good as Medicare's the whole time
- Nobody clearly told us the coverage we had wasn't as good as Medicare's
- We weren't eligible to enroll during the period the penalty is based on, or lived abroad
- A federal employee gave us wrong information about signing up for Part B
Medicare enrollment and entitlement
Start here →- Medicare application denied or delayed
- Medicare entitlement date is wrong
- Missed a Part B enrollment period
- Given wrong information by Social Security or CMS about needing to enroll
- Premium Part A enrollment denied
- Social Security's own error or inaction, not misinformation you were told directly
PACE (Program of All-Inclusive Care for the Elderly)
Start here →- PACE organization wants to reduce or stop a service
- PACE organization denied a new or increased service request
- Denied continuation of services while a Medicaid participant's appeal is pending
- Deciding between IRE review and a state fair hearing after an unfavorable PACE appeal decision
Free, but not an appeal
Complaints & grievances
Start here →A plan grievance, a QIO quality-of-care complaint, or a Medicare Beneficiary Ombudsman request — how you were treated, not a coverage decision. Always free.
Where we point you, not handle directly
Medigap (Medicare Supplement)
See where this goes →Medigap policies are sold and regulated by states, not through Medicare's own appeal system — 42 CFR § 403.201(a) leaves Medigap regulation to the states. There's no Medicare appeal to file here, but there are real, state-specific rights and places to go.
What we don't do
- Medicaid appeals (unless the case is a PACE dual-eligible continuation issue, which we do cover)
- Private commercial health insurance that isn't Medicare, Medicare Advantage, or Part D
- Employer retiree coverage that isn't itself a Medicare Advantage or Part D plan
- Immigration, disability, Social Security retirement, or SSI appeals
Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC. See Terms of Service and Privacy Policy.
