Frequently asked questions
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About CaseWhy Appeals
About CaseWhy Appeals
What does CaseWhy Appeals cover?
CaseWhy Appeals currently supports Medicare Advantage ($49 per case), Medicare Part D ($39 per case), Original Medicare ($49 per case), Medicare premiums and Extra Help ($39 per case), Medicare enrollment and entitlement ($39 per case), PACE (Program of All-Inclusive Care for the Elderly) ($39 per case). See Appeals Plus pricing for the full, current list — more coverage types are added over time.
See Appeals Plus pricing →Medicare Advantage
About CaseWhy Appeals
Is CaseWhy Appeals affiliated with Medicare, CMS, or my parent's plan?
No. CaseWhy Appeals is an independent product of CaseWhy LLC. It is not affiliated with or endorsed by Medicare, CMS, or any health plan, and nothing here is legal advice.
Why do so many appeals win?
1. A Medicare Advantage plan has to follow Traditional Medicare's coverage rules; it can't apply stricter rules of its own where Medicare's are clear. 2. Federal auditors found that many denials didn't meet Medicare's own rules in the first place — 13% of prior-authorization denials they sampled. 3. If the plan turns down your appeal, it must send the case to an independent reviewer automatically; you don't have to ask. 4. The plan has a deadline too — usually 30 days to answer a standard appeal, 72 hours if it's expedited. Miss it, and the case goes to the independent reviewer on its own. 5. None of this means every appeal wins. It means the rules are on paper, and a letter that quotes them is hard to ignore.
Read the full explanation →Who built CaseWhy Appeals, and why?
CaseWhy Appeals is built by CaseWhy LLC. It exists because most Medicare Advantage denials that would win on appeal are never appealed at all — not because the case is weak, but because nobody translates the notice into what the rule actually says and what evidence would change the answer.
Is anything CaseWhy Appeals tells me legal advice?
No. CaseWhy Appeals is not a law firm, doesn't provide legal advice, and using it doesn't create an attorney-client relationship. It explains what the governing Medicare rule requires and what evidence a winning appeal typically shows — general, informational content, never a conclusion about your specific case's outcome or a substitute for a licensed attorney or SHIP counselor.
Appeals Plus
What does CaseWhy Appeals cost?
Understanding your denial is always free: the explanation, both deadlines, the evidence checklist, reminders, and a preview of your letter. Fighting it costs $49 per case, one time, covering every level for 12 months.
See how it works and what's included →What's free with CaseWhy Appeals?
Everything that helps you understand the denial: the explanation, both deadline clocks, the evidence checklist, all reminder emails, Get Help, the fast-appeal page, and a preview of your letter. Only downloading the full letter and packet costs anything.
Is Appeals Plus a subscription?
No. Appeals Plus is a single, one-time payment of $49 per case — nothing renews or recurs, and no further charge follows for that case. It covers every letter and every appeal level for 12 months.
When am I actually charged?
Only after your appeal letter already exists for that case. The paywall never appears, and checkout is blocked, until there's a real letter to unlock — you see it before you're ever asked to pay.
What if I want a refund?
There's no automatic or self-serve refund inside the app — by design, since you never pay until a real letter already exists for your case. If something still goes wrong, email info@casewhy.com; any refund is handled directly by CaseWhy.
Deadlines and reminders
What if my parent is in the hospital right now and I only have hours?
Use the free fast-appeal page — it doesn't require signing up. It tells you the exact deadline on your notice and who to call (the QIO) in the next few hours.
How many days do I have to appeal — and why do some sites say 60?
65 days from the date on the denial notice. The rule itself gives 60 days from receipt of the notice, plus a standard 5-day mailing presumption — CaseWhy Appeals states the full 65-day figure so you're not left to do that math yourself.42 CFR 422.582
See both deadlines, explained →What are "the two clocks"?
Your deadline to file is one clock. The plan's own deadline to answer — once you've filed — is a separate, second clock. CaseWhy Appeals tracks both on your case.
What if the plan never answers?
Under the rule, the plan's silence past its own deadline is treated the same as a denial, and the case is supposed to move to the Independent Review Entity automatically.42 CFR 422.590
What if the plan doesn't respond? →How do reminders work, and how do I pause them?
You get an email before an upcoming deadline on any open case, on by default, no setup required. Every reminder includes a one-click link to pause reminders for that case, no sign-in needed.
Understanding a denial
Which notices can I upload?
Any Medicare Advantage notice or bill: an Integrated Denial Notice, a Notice of Medicare Non-Coverage, an Important Message from Medicare, a reconsideration or IRE decision, or a facility bill. A photo or a PDF both work.
Is the explanation reading my actual letter, or just guessing from the notice type?
It reads your actual document — the real text (or, for a photographed page, the real image) is what generates the explanation, not just a template for that notice type. Any Medicare number, Social Security number, or account number is redacted before anything is sent to the model that writes the explanation.
How accurate is the explanation, and how do I check a citation?
Every rule claim in the explanation carries a citation chip. Click it to see the real section it came from and the date CaseWhy Appeals last checked it. A claim with no chip was deliberately dropped rather than shown uncited — CaseWhy Appeals never shows a rule citation that didn't resolve to a real source.
Can I use CaseWhy Appeals for my parent?
Yes — most users are an adult child handling a parent's denial. You'll need the CMS-1696 form (Appointment of Representative) to file the actual appeal on their behalf; CaseWhy Appeals pre-fills it from your case.
See the CMS-1696 walkthrough →What if the notice is in Spanish?
CaseWhy Appeals currently reads and explains English-language notices only. A Spanish-language notice is a real, disclosed gap, not something it silently mishandles.
Privacy and your data
What information does CaseWhy Appeals keep about my case?
Structured facts your case actually needs — notice type, dates, the contested item, your situation answers — never the full document text or image once it's been processed, and never any portion of a Medicare Beneficiary Identifier or Social Security number. Those are redacted before anything is stored or sent to the model that writes explanations.
What happens when I delete a case or my account?
Deleting a case removes it immediately — a real, self-serve action from your case list. Deleting your whole account is also self-serve: Settings → Delete my account, permanently deletes every case and your sign-in itself, right away.
Does CaseWhy Appeals show ads or sell my data?
No, and never will. CaseWhy Appeals has no ads, no ad network, and no third-party trackers of any kind — there's nothing here for an advertiser's data to reach in the first place. We don't sell or rent your information to anyone.
Who sees my uploaded documents?
Anthropic's Claude models, which power the explanation engine, process your document's text or image to write the explanation — under Anthropic's commercial API terms, that data is not used to train its models. No advertising network of any kind has access to anything you upload.
Medicare Part D
Understanding your notice
What's the difference between a pharmacy notice and a denial notice?
A pharmacy notice ("Medicare Prescription Drug Coverage and Your Rights," form CMS-10147) isn't itself a denial you can appeal — it's a hand-out the pharmacy gives you when it can't fill a prescription, telling you to contact your plan. The plan's own written denial ("Notice of Denial of Medicare Prescription Drug Coverage," form CMS-10146) is the actual appealable decision, and it's what starts your 65-day clock.42 CFR 423.56842 CFR 423.562
What's a coverage determination, and how is it different from an appeal?
A coverage determination is your very first request to the plan — asking it to cover a specific drug, or to grant an exception (a formulary, tiering, or utilization-management exception). If the plan denies that request, THEN you have the right to appeal (a redetermination). There's no deadline to make the first request — the 65-day clock only starts once you're denied.42 CFR 423.56642 CFR 423.578
Why does the prescriber's supporting statement matter so much?
For most exception requests, the plan's own clock to decide doesn't start until it receives your prescriber's written supporting statement — and if 14 days pass with no statement, the plan can decide (usually unfavorably) without one. Getting the supporting statement in fast is often the single most important step in a Part D appeal.42 CFR 423.56842 CFR 423.572
Deadlines and reminders
Why does my drug plan's own clock run in hours instead of days?
A Part D coverage determination or redetermination is decided fast on purpose — 72 hours standard, 24 hours if expedited (7 days / 72 hours at the redetermination level). Your own deadline to file stays day-scale (65 days), but the plan's is hour-scale, which is why CaseWhy Appeals tracks both clocks separately and sends reminders at the hour, not just the day.42 CFR 423.56842 CFR 423.590
Appeals Plus
What does Appeals Plus cost for a Medicare Part D case?
$39, one time, per case — covering every appeal level for 12 months, including any later letter the case needs as it advances (a redetermination request, an IRE reconsideration request, and so on). It's not a subscription; nothing renews or recurs.
Privacy and your data
Does CaseWhy Appeals show ads or sell my data?
No, and never will. CaseWhy Appeals has no ads, no ad network, and no third-party trackers of any kind. We don't sell or rent your information to anyone.
Is the specific drug's name stored anywhere?
No. CaseWhy Appeals keeps only a coarse denial-reason category (for example, "not on the formulary" or "prior authorization") — never the drug's brand or generic name. You enter the drug name only at the moment you download a form or letter that needs it, the same way you enter your Medicare number, and it isn't stored.
Original Medicare
General
What's the difference between this and the Medicare Advantage or Part D appeal?
This pack is for Original Medicare — the red, white, and blue card, no private insurance company involved. If your parent has a Medicare Advantage plan card (Humana, UnitedHealthcare, Aetna, and others), use the Medicare Advantage pack instead; the forms can look identical, but the appeal goes to a different reviewer.
Hospital discharge, rehab ending, and observation status
Is the observation-status appeal really new?
Yes — CMS created it in a rule that took effect October 11, 2024, with hospitals required to actually issue the notice and offer the appeal starting February 14, 2025. Very few families, and not every hospital case-management office, know it exists yet.MLN Matters MM13846
My parent's hospital stay with an observation reclassification was before February 2025 — can I still appeal?
There was a one-time retrospective window for stays back to 2009, but it closed January 2, 2026. A late request is still possible for good cause — a serious illness, a death in the family, or a similar real reason the request couldn't be filed on time.42 CFR 405.942
What if I got a bill for the observation days, not a claim denial letter?
A bill by itself isn't the appeal — check first whether a Medicare Summary Notice actually denied the claim. If it did, that's the standard claims-ladder appeal this product builds too (a redetermination request to your Medicare Administrative Contractor); if you only have a bill and no MSN yet, wait for the MSN or call 1-800-MEDICARE to ask about the claim's status.
Do I need to hire someone to make this call?
No — every fast appeal in this pack starts with a single phone call you can make yourself. We give you the exact number for your state and the exact words to use.
Bills and the Medicare Summary Notice
What is a Medicare Summary Notice, and do I need to act on it?
It's a quarterly statement of every claim Medicare processed for you — most approved, some denied. Only the lines marked denied need action; the rest are informational.
How do I actually file an appeal on a denied MSN line?
Medicare's own instructions let you do it the simple way: circle the disputed line on the MSN itself, write "I do not agree with this determination" in the margin, and mail it back. A formal CMS-20027 form isn't required, though CaseWhy Appeals fills one in for you either way.
A provider billed me for something my MSN shows as denied — do I owe it?
Not necessarily. Under the limitation-on-liability rules, you generally don't owe a denied service's cost unless the provider gave you a valid Advance Beneficiary Notice before the service — and that ABN has to specifically name the service, not just be a blanket "whatever Medicare doesn't pay" notice.42 CFR 411.404
I signed an ABN — does that mean I automatically owe the bill?
Not always. The ABN has to be valid — given before the service, with a real cost estimate, no pre-checked option, and not signed during an emergency. For an ongoing course of treatment, it also has to be current: generally no more than about a year old for the dates of service actually being billed.42 CFR 411.408
My MSN says "duplicate claim" — is that something I appeal?
Usually not. A duplicate claim or a genuine billing error isn't really a coverage denial — the fix is asking the provider's billing office to correct and resubmit the claim, not filing a redetermination request.
What's the deadline to appeal a denied line on my MSN?
120 days from the date printed on the MSN, with receipt presumed to be 5 days after that date unless you can show you got it later. Good cause can extend a late filing — a serious illness, a family emergency, or not having received the notice are all reasonable explanations.42 CFR 405.942
Medicare premiums and Extra Help
Understanding your notice
What's the difference between IRMAA, Extra Help, and the Part D late-enrollment penalty?
IRMAA is a surcharge added to your Part B and/or Part D premium because your income is above a threshold. Extra Help (the Low-Income Subsidy) is the opposite — a program that lowers your Part D costs if your income is low. The late-enrollment penalty is a permanent add-on to your Part D premium for going 63 or more days without creditable drug coverage after you were first eligible. They're decided by different rules, on different deadlines, with different appeal processes — a case is on exactly one of the three.
What counts as a life-changing event for IRMAA?
Exactly 8: marriage, divorce or annulment, death of your spouse, work stoppage, work reduction, loss of income-producing property, loss of pension income, or an employer settlement payment tied to your employer's bankruptcy or closure. It's a closed list — a one-time capital gain, a Roth conversion, lottery or casino winnings, or an ordinary investment loss don't qualify, no matter how much they raised your reported income for the year.20 CFR 418.120520 CFR 418.1210
SSA says the IRS data is wrong — can I just say that on a reconsideration?
No — and this trips people up. A reconsideration filed on ONLY that ground gets dismissed. The real path is a new initial determination request, with proof (an amended return or an IRS transcript), which SSA decides directly on the corrected figures.20 CFR 418.1330
Deadlines and reminders
Why does the Part D penalty deadline work differently from everything else?
Every other deadline in this product runs from when you RECEIVED the notice, with a 5-day mailing allowance built in. The Part D late-enrollment penalty reconsideration is the one exception — its 60-day clock runs from the date printed ON the letter itself, not when it arrived. Keep paying the penalty while your reconsideration is pending; stopping risks disenrollment from your plan.42 CFR 423.46
How long does Social Security take to decide?
There's no fixed decision deadline in the rule for an IRMAA or Extra Help case — unlike a Part D plan or the Part D penalty reconsideration process, which both have a real clock. We send a check-in reminder at 30 and 60 days after you file, since checking in yourself is the only way to know where things stand.
Appeals Plus
What does Appeals Plus cost for a Medicare Premiums case?
$39, one time, per case — covering every appeal level for 12 months, including any later letter the case needs as it advances. It's not a subscription; nothing renews or recurs.
Privacy and your data
Does CaseWhy Appeals show ads or sell my data?
No, and never will. CaseWhy Appeals has no ads, no ad network, and no third-party trackers of any kind. We don't sell or rent your information to anyone.
Is my income or Social Security number stored anywhere?
No. Any dollar amount you type into an explanation or note is automatically detected and removed before anything is saved — the same discipline this product already applies to Social Security numbers everywhere. You enter your income figures and Medicare number only at the moment you download a form that needs them, and they aren't stored.
Medicare enrollment and entitlement
Understanding your notice
What's the difference between a denied application and federal misinformation?
A denied application means Social Security reviewed your specific request and said no, for a stated reason. Federal misinformation is different — you were told something wrong by a federal employee (for example, "you don't need Part B yet") and are now facing a penalty or a gap as a result. The first is an ordinary reconsideration; the second is a separate, discretionary relief request under 42 CFR § 407.32.
I was told by my employer, not a government employee, that I didn't need to enroll — does that count?
Not under 407.32, which covers only a federal employee's own error, misrepresentation, or inaction. But a separate special enrollment period (42 CFR § 406.27(c)) exists specifically for misinformation from an employer, health plan, or an agent or broker — a real, different path with its own real requirements.42 CFR 407.3242 CFR 406.27
Deadlines
Do I have to use a specific form to request reconsideration?
A written request is required (SSA's own reconsideration regulation, unlike some other Social Security appeal processes, does not accept an oral request) — the SSA-561-U2 form makes sure nothing gets left out, though a clear written letter with the same information generally works too.20 CFR 404.909
How long does Social Security take to decide?
There's no fixed decision deadline stated in the corpus for a reconsideration at this level — a real, disclosed gap in the rule itself, not something this product can promise a timeline for.
Appeals Plus
What does Appeals Plus cost for a Medicare enrollment case?
$39, one time, per case — covering every appeal level for 12 months, including any later letter the case needs as it advances.
Privacy and your data
Is my Social Security number stored anywhere?
No. Social Security numbers are fully redacted before anything is stored, and no work history or employer name is stored either — the same discipline this product already applies everywhere else.
PACE (Program of All-Inclusive Care for the Elderly)
Understanding your notice
What's the difference between a grievance and an appeal?
A grievance is a complaint about service delivery or quality of care, regardless of whether you want anything changed as a result — resolved within 30 days, with a right to also file a quality-of-care complaint with the QIO. An appeal is specifically about a service determination — a denial, reduction, or termination of a service — with its own real deadlines and levels of review.42 CFR 460.12042 CFR 460.122
Does the PACE organization have to see my parent in person before reducing a service?
Yes, if it expects to deny or partially deny the request — an in-person reassessment by the appropriate team members is required first, evaluating whether the service is still necessary for your parent's medical, physical, emotional, and social needs.42 CFR 460.121
Deadlines
Can services keep going while we appeal?
Every required service continues for everyone during a grievance or an appeal. A Medicaid participant has an additional right: if the PACE organization is reducing or stopping a service you're already getting, you can ask to keep that specific service going too, understanding you may be liable for its cost if the final decision goes against you.42 CFR 460.12042 CFR 460.122
My parent has both Medicare and Medicaid — which external review do we use?
A dual-eligible participant can choose either the Independent Review Entity (the Medicare path) or a state fair hearing (the Medicaid path) — but only one, not both.42 CFR 460.124
Appeals Plus
What does Appeals Plus cost for a PACE case?
$39, one time, per case — covering every appeal level for 12 months, including any later letter the case needs as it advances.
