Medicare Fee-for-Service (Traditional Medicare)
Also known as: Medicare, Traditional Medicare, Original Medicare, Medicare FFS, CMS Medicare, Medicare Part A, Medicare Part B
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
- 1Always file Level 1 redetermination — most denials are not appealed but overturn rates are significant
- 2Reference specific NCDs and LCDs in your appeal
- 3For SNF/home health denials, cite Jimmo v. Sebelius — Medicare cannot deny based on lack of improvement
- 4For inpatient status disputes, cite the 2-midnight rule and provide documentation of expected stay duration
- 5Request the MAC's clinical review file to understand the basis for denial
Known Weaknesses
- ALJ hearings (Level 3) have historically high overturn rates (70%+)
- QIC reconsiderations (Level 2) also have favorable overturn rates
- 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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Upload Your Denial — FreeThis information is for educational purposes based on publicly available data including CMS reports, state insurance department filings, and published insurer guidelines. It does not constitute legal, medical, or financial advice. Individual results vary. Verify all information independently and consult qualified professionals before acting.