Court and appeal decisions, explained

Real rulings, settlements, and federal oversight reports — what was decided, and what it means for your appeal.

• Jimmo v. Sebelius

  Medicare contractors had been applying an unwritten "Improvement Standard" — denying skilled nursing, home health, and outpatient therapy coverage whenever

• Iron Run Orthopedics

  Applying Jimmo directly: a beneficiary's lack of potential for improvement can't, by itself, justify denying skilled-care coverage. The plan or contractor

• Barrows v. Becerra (following Alexander v. Azar, D. Conn.)

  Affirmed that Original Medicare patients who are admitted to a hospital as an inpatient and then reclassified to outpatient "observation" status during the

• OIG OEI-09-16-00410 — Medicare Advantage Appeal Outcomes and Audit Findings

  Enrollees and providers appealed only about 1% of denials, even though independent reviewers overturned a large share of the denials that were appealed — e

• OIG OEI-09-18-00260 — Some MA Organization Denials of Prior Authorization Requests Raise Concerns

  A sample of denied prior-authorization requests found that 13% of the denials, and 18% of denied payment requests, actually met Medicare's own coverage rul

• OIG OEI-09-24-00331 — MAOs Overturned Nearly All Appealed SNF Prior-Authorization Denials

  95% of appealed skilled nursing facility prior-authorization denials were overturned — nearly every SNF denial that was actually appealed turned out to be

• "Refusal of Recovery" — Majority Staff Report on Medicare Advantage

  An investigation into the three largest Medicare Advantage insurers found they denied post-acute care (skilled nursing, inpatient rehab, and similar) at fa