An Ohio Story About Medicare Advantage Appeals, and How to Win

“They Said No.” An Ohio Story About Medicare Advantage Appeals, and How to Win

Updated for 2025: New Timelines, Success Stats, and the Reality Check Every Ohioan Needs

The Power of One Appeal: Shirley’s Ohio Journey

Shirley from Portsmouth isn’t a complainer. Thirty years of teaching first graders made her patient. A calendar stuck to the fridge with a Buckeyes magnet kept her medical life organized. Then came the letter: her Medicare Advantage plan denied the infusion her specialist ordered. “Not medically necessary,” said the notice. Shirley’s hands shook as she dialed her nurse. “You can appeal,” she said, but everything that came after sounded like static.

If you’re staring at a denial letter, feeling lost or angry, you are not alone. You are not powerless. Ohio appeals follow clear federal rules: five levels, protected timelines, and real data showing perseverance pays.¹

First: The Truth Most People Don’t Know

Most beneficiaries never appeal a denial. Insurance jargon, tight deadlines, and fatigue take their toll. But statistics reveal hidden hope:

In 2023, Medicare Advantage plans denied 3.2 million prior authorization requests nationally. Fewer than one in ten were appealed, but 81.7% of those appeals led to overturned denials, insurance plans said “yes” after a second look.²

At the Independent Review Entity (IRE) level, success rates are much lower but vary significantly by service type. Recent Commonwealth Fund analysis shows a 3% overall IRE success rate, with emergency room visits succeeding at 6.3% while durable medical equipment appeals succeed at only 1.7%. The key insight: most success happens at Level 1 with your plan, making that first appeal critically important.³

You’re not asking for charity. You’re exercising rights built into your coverage. Every appeal helps people get the care they need.

The Ohio Medicare Advantage Appeals Roadmap

Level 1: Reconsideration by Your Plan

• File within 65 days of denial (changed from 60 days effective January 1, 2025).⁴
• Decisions: 30 days for standard pre-service appeals, 60 days for payment, 7 days for Medicare Part B drugs.
• If the health risk is urgent, request an expedited review. The insurance provider must issue a decision in 72 hours.⁵
• Your plan may take a 14-day extension for good cause, but you must be notified.⁶

Level 2: Independent Review Entity (IRE)

• If denied again, your case is automatically forwarded to the independent reviewer (IRE/Maximus), so there is no need to refile.⁷
• Identical decision clocks apply: 30 days standard, 7 days drugs, 60 days payments, 72 hours.
• You can submit additional evidence within 10 days.⁸

Level 3: Administrative Law Judge (ALJ) Hearing

• If the IRE upholds the denial, request an Administrative Law Judge (ALJ) hearing at the Office of Medicare Hearings and Appeals (OMHA) within 60 days. Minimum Amount in Controversy (AIC) threshold is $190 for 2025.⁹

Level 4: Medicare Appeals Council

• If you disagree with the ALJ, you have 60 days to request Council review.¹⁰

Level 5: Federal District Court

• Seek judicial review if the AIC threshold ($1,900 in 2025) is met and you’ve exhausted other levels.¹¹

Special Cases: Fast Hospital/Hospice Discharge

• If you’re discharged early, the right process is through the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). Follow instructions on the discharge notice. Be alert because deadlines are short.¹²

Inside Your Appeal: Building a Winning Packet

Build a strong bridge for the reviewer:

• The doctor’s letter addresses every reason for the denial, cites guidelines, and explains the harm from delay.
• Attach clinical guidelines or peer-reviewed studies.
• Provide recent records: notes, labs, imaging, and medication lists.
• Include a clear cover letter explaining why the care matters now.

Evidence beats opinions. Reviewers need facts, not just statements.

Ohio’s Common Stumbling Points (And How to Dodge Them)

• Missing the clock: Don’t miss your Level 1 deadline. File early. The 65 days go fast.
• Expedited review: Request it if health is at risk. You will receive a decision in 72 hours.
• Stopping after one denial: If the plan says no again, it automatically goes to the IRE. Never quit at the first “no.”
• Sending opinions, not records: Support your appeal with hard evidence.
• Late filing: If late, ask for a “good cause” exception and explain what happened. It’s built into the Centers for Medicare & Medicaid Services (CMS) guidance.¹³

Quick Action: Your One-Page Roadmap

1. Read the denial letter. Circle its reason or reasons for denial.
2. Call your provider for a medical necessity letter with guideline citations.
3. Gather 90 days of records: notes, labs, and imaging.
4. File Level 1 appeal well before Day 65. If late, add a “good cause” note.
5. Request expedited review if warranted.
6. Watch for the IRE notice. Level 2 begins automatically if your plan says no.
7. Call OSHIIP (Ohio Senior Health Insurance Information Program) at 800-686-1578 for guidance. They inform but do not give legal advice.¹⁴

Recent Trends: The Bigger Picture

Good news for Ohio beneficiaries: Medicare Advantage denial rates decreased in 2023 to 6.4% from 7.4% in 2022, even as prior authorization requests increased. However, denial rates vary dramatically by insurer, from Humana’s 3.5% to Centene’s 13.6%, making appeals knowledge even more crucial depending on your plan.²

When Not to Go It Alone

• Overwhelmed with the complexity of the process
• Looming deadlines or health risks
• High-risk treatments
• Complex records or denied care
• IRE or ALJ decision against you
• Doctors are too busy to write a good letter

A skilled advocate shapes your record, manages deadlines, and frames strong arguments.

Shirley’s Outcome: A Path You Can Walk

Her specialist wrote a focused letter using the plan’s criteria. Armed with records, labs, and proof of harm from delay, Shirley requested expedited review. The plan said no, but when she appealed to the IRE, it reversed the denial, and her infusion was approved.

Every case is unique. But what matters is the existence of the appeals process, and the fact that you don’t have to walk it alone.

If You Want Help

• Free 10-minute triage call: Plan type, deadlines, and next steps identified.
• Flat-fee document check: You draft your appeal, and we sanity-check for gaps or mistakes.
• Full-service appeal: Frank Mungo advocates for you from start to finish.

Important: This article is general information, not legal advice. Reading it does not create an attorney-client relationship. The author, Frank Mungo, is licensed in Ohio and Kentucky. Services are only offered where permitted, and no results are promised.

FAQ

How long do I have for the first appeal?
65 days from the denial date (changed from 60 days in January 2025). Request “good cause” if you’re late.⁴

How fast is expedited review?
Within 72 hours for the plan and IRE if your health is at risk.⁵

What happens if Level 1 is denied?
Your case is automatically forwarded to the IRE. No need to refile.⁷

Who can I call in Ohio for guidance?
OSHIIP at 800-686-1578, for neutral, non-legal guidance.¹⁴

What are my realistic chances at the IRE level?
Overall success rate is about 3% but varies significantly by service type. Emergency room visits succeed at 6.3% while durable medical equipment appeals succeed at only 1.7%.³

Cheat-Sheet Checklist (Printable version available)

• Reason for denial highlighted
• Doctor’s letter with guideline citations requested
• 90 days of records gathered
• Level 1 appeal date and deadline marked
• Expedited request if risk is present
• Watch for the IRE notice after Level 1
• If you are late, add a good cause note

Acronym Guide

• IRE: Independent Review Entity
• ALJ: Administrative Law Judge
• OMHA: Office of Medicare Hearings and Appeals
• AIC: Amount in Controversy
• BFCC-QIO: Beneficiary and Family Centered Care-Quality Improvement Organization
• CMS: Centers for Medicare & Medicaid Services
• OSHIIP: Ohio Senior Health Insurance Information Program

Sources & Success Statistics

• gov: Official appeal timelines and process
• KFF: Prior authorization denials, appeal rates, and overturn statistics
• Commonwealth Fund: IRE success rate analysis by service type
• CMS & MAXIMUS Fact Sheets: Thresholds, volumes, and success rates
• State of Ohio: OSHIIP hotline for public guidance

Footnotes

¹ Medicare.gov. “Appeals in Medicare health plans.” https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans

² KFF. “Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Requests in 2023.” January 29, 2025. https://www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/

³ Commonwealth Fund. “More Medicare Advantage Beneficiaries Are Filing Appeals for Denied Services or Treatments.” October 8, 2024. https://www.commonwealthfund.org/blog/2024/more-medicare-advantage-beneficiaries-are-filing-appeals-denied-services-or-treatments

⁴ CMS. “Reconsideration by the Medicare Advantage (Part C) Health Plan.” https://www.cms.gov/medicare/appeals-grievances/managed-care/reconsideration-advantage-health-plan-part-c

⁵ Medicare.gov. “Appeals in Medicare health plans – Expedited Reviews.” https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans

⁶ CMS. “Medicare Managed Care Appeals & Grievances.” https://www.cms.gov/medicare/appeals-grievances/managed-care

⁷ CMS. “Reconsideration by Part C Independent Review Entity (IRE).” https://www.cms.gov/medicare/appeals-grievances/managed-care/review-part-c-independent-entitiy

⁸ Medicare.gov. “Level 2: Independent Review Entity (IRE).” https://www.medicare.gov/claims-appeals/file-an-appeal/medicare-health-plan-appeals-level-2-independent-review-entity-ire

⁹ Federal Register. “Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2025.” September 27, 2024. https://www.federalregister.gov/documents/2024/09/27/2024-22142/medicare-program-medicare-appeals-adjustment-to-the-amount-in-controversy-threshold-amounts-for

¹⁰ CMS. “Medicare Managed Care Appeals & Grievances – Level 4.” https://www.cms.gov/medicare/appeals-grievances/managed-care

¹¹ CMS. “Federal District Court Review.” https://www.cms.gov/medicare/appeals-grievances/managed-care/federal-district-court-review

¹² Medicare.gov. “Fast appeals.” https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/fast-appeals

¹³ CMS. “Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.” https://www.cms.gov/medicare/appeals-and-grievances/mmcag/downloads/parts-c-and-d-enrollee-grievances-organization-coverage-determinations-and-appeals-guidance.pdf

¹⁴ Ohio Department of Insurance. “Ohio Senior Health Insurance Information Program (OSHIIP).” https://insurance.ohio.gov/about-us/divisions/oshiip

Copyright 2025. For educational use only.