The appeal paradox

A Medicare Advantage plan may not apply coverage rules stricter than Traditional Medicare's where Medicare's rules are clear, and may use its own internal criteria only where they aren'trule42 CFR § 422.101(b). When federal auditors sampled denials, 13% didn't meet Medicare's own coverage rulesruleHHS OIG, April 2022 (OEI-09-18-00260). A 2024 Senate investigation found the three largest insurers used predictive tools and targeted post-acute care with denials that rose sharply year over yearruleSenate PSI Majority Staff Report, Oct 17, 2024. An appeal puts the denial in front of a physician reviewerrule42 CFR § 422.590 and, if the plan upholds it, an independent reviewer the plan must forward the case torule42 CFR § 422.590. The initial denial is a filter. The appeal is the first real review.

Nobody knows how many of the 3.6 million unappealed denials would have been reversed. What we do know is what appealing demands: a five-level processruleMedicare.gov — Filing an appeal (5 levels); a filing window of 65 days from the date on the noticerule42 CFR § 422.582; a plan decision that takes up to 30 days for care not yet received, 60 for a bill, or 72 hours if expeditedrule42 CFR § 422.590; and a notice written in the plan's language, arriving when the person it concerns is often sick, elderly, or in a hospital bed. Families don't skip the appeal because they're wrong. They skip it because nobody tells them what the rule says, what the deadline is, or where to send the letter.