Not medically necessary. Prior authorization rejected by your Medicare Advantage plan. Hospital wants to discharge you before you are ready. Medicare has a formal four-level appeal process — and most beneficiaries never use it. ClaimCompass reads your denial and writes your appeal — free to start.
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Medicare and Medicare Advantage denials follow predictable patterns. Every one has a defined appeal process — and success rates increase at every level.
Why it overturns: Medicare's medical necessity criteria are set by CMS National Coverage Determinations and Local Coverage Determinations — specific, documented standards that your physician's order must address. Most "not medically necessary" denials occur because the clinical documentation submitted with the claim did not explicitly address every criterion in the applicable LCD for that service. A well-prepared appeal fills that gap: your physician provides a detailed letter of medical necessity addressing each criterion by name, citing the diagnosis, functional limitations, failed alternatives, and clinical rationale using the exact language of the applicable LCD. Physicians' offices often submit claims without this level of documentation — not because the care wasn't necessary, but because the paperwork burden is enormous. Your appeal corrects the record.
Why it overturns: Medicare Advantage plans are required by federal law to cover everything that Original Medicare covers — they cannot apply more restrictive medical necessity criteria than CMS applies to original Medicare. When a Medicare Advantage plan denies a prior authorization for a service that Original Medicare would cover, that denial is challengeable on that basis alone. Your appeal should demonstrate that the requested service meets Original Medicare coverage criteria, cite the applicable NCD or LCD, and request the plan to produce its clinical criteria for comparison. Urgent and expedited prior authorization appeals must be decided within 72 hours — and if your health is at serious risk, that timeline is legally enforceable. External review by an Independent Review Organization is available if the internal appeal fails.
Why it overturns: The observation vs. inpatient status distinction has enormous financial consequences — it determines whether Medicare Part A covers your stay and any subsequent skilled nursing facility care. This appeal must be filed while you are still in the hospital — once discharged, the process changes significantly. File an immediate expedited appeal with the BFCC-QIO (Beneficiary and Family Centered Care Quality Improvement Organization) — the hospital cannot discharge you or bill you for inpatient services while the QIO review is pending. Your physician's clinical documentation supporting the continued medical necessity of inpatient-level care is the foundation of a successful QIO appeal. Success rates for QIO appeals supported by treating physician documentation are meaningful — and the potential financial benefit makes the appeal well worth filing.
From denial letter to appeal-ready in about 3 minutes. Medicare's process has strict deadlines — start now.
Take a photo or upload a PDF — that's really all it takes.
Your Medicare Summary Notice, Explanation of Benefits, prior authorization denial, discharge notice, or any Medicare or Medicare Advantage correspondence. PDF or a phone photo works. Your document is handled securely and automatically deleted if you do not continue. No account needed to start.
Within seconds — plain English, no Medicare jargon.
Our AI analyzes your denial, identifies the specific basis — medical necessity, prior authorization, discharge, or other grounds — and gives you a viability score from 0 to 100. You receive a plain-English explanation of the applicable Medicare coverage criteria, your appeal rights at every level, and the specific documentation that will support your challenge. Critically, we identify your appeal deadline — Medicare timelines are strict. Completely free.
Formally written, CMS-standard, ready to file — for $49.
ClaimCompass generates a complete, personalized appeal letter challenging the specific denial — citing the applicable National Coverage Determination, Local Coverage Determination, Medicare Advantage federal requirements, or QIO standards as appropriate. Every level of appeal is included: Redetermination, Qualified Independent Contractor review, ALJ hearing, and beyond. One payment. No additional charge if the first appeal is denied.
A score above 70 means you have a solid case worth pursuing. Medicare appeals succeed at increasing rates at higher levels — most beneficiaries who ultimately prevail do so at the ALJ hearing level. Acting quickly protects your rights at every level.
Upload your Medicare denial, prior authorization notice, or discharge letter. In under a minute, you will know exactly where you stand — and your appeal deadline.
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