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September 27, 2026
Sunrise PACE Organization — Appeals Department
RE: Requesting an appeal of the service determination described below under 42 CFR § 460.122, reviewed by an impartial third-party reviewer — Walter Sample, plan member ID ••••DEMO, denial dated 2026-07-10, PACE organization wants to reduce or stop a service
On 2026-07-10, the third-party reviewer denied the item or service described below. The stated reason was: "Based on a review of your file, the interdisciplinary team has determined that your current level of home health aide support is no longer necessary."
I am appealing the PACE organization's decision to reduce aide visits based on the assertion that my family member's needs have decreased. Under 42 CFR § 460.121(h)(1), when the interdisciplinary team expects to deny or partially deny a service determination request—which includes reducing services—the appropriate team members must conduct an in-person reassessment before making a final decision. The regulation explicitly requires that team members performing the reassessment evaluate whether the requested service is necessary to meet the participant's medical, physical, emotional, and social needs. The third-party reviewer is required to examine whether such a reassessment actually occurred and whether it properly evaluated all dimensions of need, not merely whether the organization asserts that needs have decreased.
The governing rule at 42 CFR § 460.121(g) mandates that the interdisciplinary team must consider all relevant information when evaluating a service determination request, including the findings and results of any reassessments, as well as the criteria specified in . A bare assertion that needs have decreased does not satisfy this requirement. The third-party reviewer must determine whether the organization's decision was grounded in documented reassessment findings that address the participant's medical, physical, emotional, and social needs comprehensively, or whether the reduction was based on insufficient clinical evaluation.
Furthermore, 42 CFR § 460.121(j)(2)(i) requires that any notice of denial must state the specific reason for the denial and explain why the service is not necessary to maintain or improve the participant's overall health status, taking into account medical, physical, emotional, and social needs. The third-party reviewer must assess whether the organization's stated rationale—that needs have decreased—constitutes a sufficiently specific and documented reason grounded in reassessment, or whether it represents an inadequate basis for reducing services that the participant currently receives.
The facts as I understand them:
The interdisciplinary team did not conduct an in-person reassessment before deciding to reduce or stop the service.
No team members saw my parent in person for this reassessment.
My parent's medical, physical, emotional, or social needs have not changed since the service was last approved.
The written denial notice did not explain specifically why the service is no longer necessary.
Requesting an appeal of the service determination described below under 42 CFR § 460.122, reviewed by an impartial third-party reviewer
Signed by the enrollee's representative, per the attached Appointment of Representative (CMS-1696).