PACE (Program of All-Inclusive Care for the Elderly) denied keeping a service going while your appeal is pending? What the rule says and how to appeal.
Checked against the current rules on September 24, 2026.
A denial for keeping a service going while your appeal is pending isn't the end of the story — PACE organizations have to follow specific coverage rules, and a denial that doesn't square with those rules is exactly the kind of appeal that tends to win.
Here's what the rule actually requires, what evidence usually turns a denial around, and the deadline you're working against.
What the rule requires
Coverage for keeping a service going while your appeal is pending under your PACE organization is governed by§ 460.122 PACE organization's appeals process.. Your PACE organization generally cannot apply a stricter test than what these rules require.
Questions that decide it
Before you appeal, these are the facts that usually decide whether a denial like this holds up:
Is your parent a Medicaid participant (not Medicare-only)?
Did you actually request that the disputed services continue while the appeal is pending?
Did you make that request in writing, or note the date and method if it was made by phone?
Has the PACE organization told you, in writing, whether you could be liable for the cost of the continued service if the appeal doesn't succeed?
What a winning appeal has to show
An appeal that wins usually includes:
Proof of Medicaid participation — This continuation right — keeping the disputed services going until the final determination — applies specifically to Medicaid participants; a Medicare-only participant does not have this same right, though every required service continues for everyone during the appeal regardless. (You or your family provide this.)42 CFR 460.122
A copy of your written request to continue the disputed service during the appeal, or a dated note of the request if made by phone — A documented, timely request removes any later dispute about when you asked and exactly what you asked to keep going. (You or your family provide this.)42 CFR 460.122
Any written notice from the PACE organization about possible liability for the cost if the appeal doesn't succeed — Continuing a disputed service during a Medicaid participant's appeal can come with liability for its cost if the final decision goes against you — the organization's own notice on this point is worth having in writing before you decide whether to request continuation. (You or your family provide this.)42 CFR 460.122
Your deadline to appeal
No deadline to make this first request — a participant, their designated representative, or their caregiver may request it at any time, orally or in writing.42 CFR 460.121
Your PACE organization itself then has its own clock to decide. As expeditiously as the participant's condition requires, but no later than 3 calendar days from the request — extendable by up to 5 calendar days.
Questions people ask
- Can your PACE organization just say it's "not medically necessary" with no further explanation?
- The denial notice has to explain the basis for the decision and tell you how to appeal. If it doesn't point to a specific rule or criteria, that's itself worth raising in your appeal — you're entitled to know what standard was applied.
- What if I don't have all the evidence listed above?
- Include what you have. An appeal with partial evidence and a clear explanation of the rule still gets a real review — it doesn't need to be complete to be worth filing.
Sources — last checked September 24, 2026
- § 460.122 PACE organization's appeals process.as of September 24, 2026
- 42 CFR 460.121as of September 24, 2026
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
