Understanding Medicare Appeals After a Stroke

The five levels of Medicare appeal

Medicare gives beneficiaries five separate chances to overturn a denial. Each level has its own form, deadline and decision-maker.

1. Redetermination by the Medicare Administrative Contractor.
2. Reconsideration by a Qualified Independent Contractor.
3. Administrative Law Judge hearing.
4. Medicare Appeals Council review.
5. Federal District Court review.

Most stroke-related denials are resolved at levels one or two.

What evidence tends to win

The single most effective piece of evidence is a letter of medical necessity from the treating neurologist or physiatrist that ties the requested service to the patient's specific deficits and rehabilitation potential. Generic letters fail. Specific ones succeed.

Timelines

You generally have 120 days to file a redetermination after receiving the Medicare Summary Notice. Reconsideration must be requested within 180 days of the redetermination decision. Mark these dates the moment a denial arrives.

Medicare Advantage is different

Medicare Advantage plans have their own internal appeal pathway followed by an automatic Independent Review Entity review if the plan upholds its denial. This automatic forwarding is one of the few protections that the original Medicare program does not provide.

When to ask for help

If a denial involves inpatient rehabilitation, skilled nursing transfer, durable medical equipment or speech therapy duration, a healthcare advocate or attorney specializing in Medicare can often raise the success rate substantially.