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Insurer Playbook

Medicare Fee-for-Service (Traditional Medicare)Denial patterns and how to appeal

Also known as: Medicare, Traditional Medicare, Original Medicare, Medicare FFS, CMS Medicare, Medicare Part A, Medicare Part B

Medicare Part AMedicare Part BMedicare Part D

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Known denial patterns

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Appeal best practices

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Points to check

Common Denial Patterns

  • Medical necessity denials based on NCDs/LCDs
  • Inpatient vs observation status disputes (2-midnight rule)
  • Skilled nursing facility (SNF) coverage denials based on improvement standard (prohibited by Jimmo v. Sebelius)
  • Home health certification denials
  • DME coverage denials for mobility devices and CPAP

Appeal Best Practices

  1. 1Always file a Level 1 redetermination with the MAC within 120 days of receiving the initial determination notice
  2. 2Reference specific NCDs and LCDs in your appeal
  3. 3For SNF/home health denials, cite Jimmo v. Sebelius — Medicare cannot deny based on lack of improvement
  4. 4For inpatient status disputes, cite the 2-midnight rule and provide documentation of expected stay duration
  5. 5Request the MAC's clinical review file to understand the basis for denial

Points to Check

  • An ALJ hearing (Level 3) is available after the QIC reconsideration; ask for it
  • A QIC reconsideration (Level 2) is available if the redetermination is denied; ask for it
  • Jimmo v. Sebelius prohibits improvement standard — powerful for maintenance therapy denials
  • Medicare coverage is governed by law, not insurer discretion — legal standards apply

Contact & Response

Best Contact Method

Written redetermination to MAC > QIC reconsideration > ALJ hearing

Typical Response Time

60 days (redetermination), 60 days (reconsideration), 90 days (ALJ)

Internal Criteria Used

  • National Coverage Determinations (NCDs)
  • Local Coverage Determinations (LCDs)
  • Medicare Claims Processing Manual

State-Specific Notes

ALL

Medicare FFS is federal — same rules in all states. State insurance departments do not have jurisdiction over Medicare FFS.

General Tips

  • Medicare FFS has a standardized 5-level appeal process established by law (42 CFR Part 405)
  • Level 1: Redetermination by the Medicare Administrative Contractor (MAC) — 120 days to file
  • Level 2: Reconsideration by a Qualified Independent Contractor (QIC) — 180 days
  • Level 3: Administrative Law Judge (ALJ) hearing — $180 minimum in dispute
  • Level 4: Medicare Appeals Council review
  • Level 5: Federal District Court — $1,760 minimum in dispute
  • Medicare coverage is governed by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)

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This is general guidance compiled by Lysco. Check it against your plan documents and the notice you received, which set the rules for your appeal. It does not constitute legal, medical, or financial advice. Individual results vary. Verify all information independently and consult qualified professionals before acting.