Seniors can indeed **appeal if Medicare denies coverage for long-term care**, but the process can be complex and requires prompt action. Medicare generally does not cover long-term custodial care in nursing homes or assisted living facilities unless it is medically necessary skilled care, so denials are common. However, when Medicare denies coverage, seniors have the right to challenge that decision through a structured appeals process.
When Medicare denies long-term care coverage, the first step is to carefully review the denial notice to understand the reason for denial and the deadline for filing an appeal. For traditional Medicare, the appeal process typically begins with a request for a reconsideration or review by the Medicare contractor or Quality Improvement Organization (QIO) assigned to the state. This initial appeal must usually be filed within about 60 to 65 days from the date of the denial notice. If the appeal is urgent—meaning that waiting could seriously harm the senior’s health—there is an option to request an expedited appeal, which is handled faster.
The appeals process for Medicare coverage denials generally follows multiple levels:
1. **Level 1: Plan Reconsideration or QIO Review**
This is the first and often most successful step. The senior or their representative submits an appeal to the Medicare plan or QIO that made the denial decision. Plans overturn denials at this stage about 80% of the time. The plan or QIO must respond within 30 days for standard appeals or within 72 hours for expedited appeals.
2. **Level 2: Independent Review Entity (IRE) or Qualified Independent Contractor (QIC)**
If the initial appeal is denied, the case moves to an independent reviewer who has no connection to the plan. This reviewer reassesses the evidence and makes a new decision, again within similar timeframes.
3. **Level 3: Administrative Law Judge (ALJ) Hearing**
If the denial persists, the senior can request a hearing before an ALJ. This level requires that the amount in controversy meets a minimum threshold (for example, $190 in 2025). The ALJ hearing is more formal and allows the senior to present evidence and testimony.
4. **Level 4: Medicare Appeals Council Review**
If the ALJ denies the appeal, the senior can request a review by the Medicare Appeals Council, which examines the ALJ’s decision.
5. **Level 5: Federal District Court**
The final level is
