Medicare rules, explained
The real rules a Medicare Advantage denial and appeal actually turn on — plain language, every claim cited to its real source.
- How a Medicare Advantage plan has to decide your request
What an "organization determination" is, and the notice and timeframe rules that apply before you ever file an appeal.
- How a plan's reconsideration (Level 1 appeal) works
The physician-reviewer requirement and the plan's own deadline to decide your first-level appeal.
- The Independent Review Entity (IRE), explained
Who reviews your case at Level 2, and why it isn't the plan reviewing itself again.
- The ALJ hearing and the amount-in-controversy threshold
What it takes to reach a judge, and the dollar-value rule that applies before you can.
- NOMNC and Important Message: your same-day fast-appeal rights
The two notices that come with an accelerated, same-day appeal option through an outside reviewer.
- The coverage-criteria rule every MA plan has to follow
Why a Medicare Advantage plan can't simply apply a stricter test than Traditional Medicare's own coverage rules.
- The CMS Parts C & D Appeals Guidance: the operative rulebook
Why this one CMS guidance document, not the regulation text alone, spells out most of the deadlines and procedures an appeal actually runs on.
- The two-midnight rule: inpatient vs. observation, explained
The benchmark that decides whether a hospital stay counts as inpatient admission or outpatient "observation."
- Home health: the homebound test and the skilled-need test
The two separate tests a home health denial usually turns on — and why "not improving" isn't a valid reason to deny either one.
- Skilled nursing facility coverage: the level-of-care test
What "skilled nursing facility level of care" actually requires, the 3-day-stay rule's real status under Medicare Advantage, and why "no improvement" isn't a valid denial reason.
- CPAP and home oxygen: the specific test numbers that decide coverage
The exact sleep-test and blood-gas thresholds Medicare requires — and why a denial usually turns on a missing number, not a judgment call.
- Power wheelchairs and scooters: the coverage test
The specific things a power mobility device request has to document — and why a home visit and a lesser-device trial both usually matter.
- How fast a plan has to decide a prior-authorization request
A 2024 rule shortened Medicare Advantage plans' own decision deadline before you ever reach the appeal stage.
- The Medicaid half of a dual-eligible appeal: the state fair hearing
When a Dual Eligible Special Needs Plan denies something Medicaid would have covered, the Medicaid half of that denial goes to your state's own fair-hearing process — not to the same independent reviewer that handles the Medicare half.