Several people can help you fight a Medicare denial, and each one owns a different piece of it: the reviewer the letter names, your dad’s doctor, your state’s Medicare counseling program, an elder law attorney if the appeal climbs, and someone who can read the denial against the care it stops paying for and the stage of the disease it lands in. If the letter in front of you is three pages of codes and abbreviations with a date that already feels too close, that list can sound like more phone calls rather than fewer. Your dad still needs the care the letter refused, and the worry at this point is often less about the bill than about calling the wrong person first and losing the window while you work out who the right one was.

Jessica Lizel Cannon of The Proactive Caregiver, a dementia caregiving strategist, is the person on that list who does the part that usually belongs to nobody: putting the denial, the care contract and the dementia timeline on the same page, so the family can see what the appeal is worth and what the waiting will cost. She is a CPA with 28 years of financial experience and a Certified Dementia Practitioner, and she spent more than 15 years caring for her own mother through frontotemporal dementia and four misdiagnoses, so she knows these systems from the family’s side of the table.

Start with the letter, because the letter sets the deadline. The rules are federal; where a state program matters, Texas is the worked example. If services are ending in the next day or two, her step-by-step checklist for appealing a hospice discharge or Medicare denial has the calls and documents for that moment.

Estimated reading time: 11 min read

Key Insights

A Medicare denial comes with a deadline and several owners. The notice names the reviewer and the clock: the date printed on a Medicare Summary Notice, 65 days on a Medicare Advantage denial, noon the day before services end on a Notice of Medicare Non-Coverage. A skilled-care denial cannot rest on lack of improvement alone, a parent who can no longer sign needs someone with legal authority to act for him, and some denials simply enforce Medicare’s custodial-care exclusion, where the work becomes a funding plan.

Table of Contents

• 1. The reviewer named on the letter decides first
• 2. Your parent’s doctor supplies the evidence
• 3. A SHIP counselor reads the letter with you
• 4. Someone needs the authority to speak for your parent
• 5. Legal help, for when the appeal climbs
• 6. A dementia caregiving strategist reads the denial against the money and the timeline
• 7. When the denial follows the rules, the fight becomes a funding plan
• What to bring to the first conversation
• When the letter still does not make sense

1. The reviewer named on the letter decides first

Every denial notice says who decides the next step and how long you have. A Medicare Summary Notice is the statement Original Medicare sends after a claim, and Medicare says the first appeal, called a redetermination, must be filed by the date printed on it; CMS’s request form asks for a reason if the notice arrived more than 120 days earlier. A denial from a Medicare Advantage plan goes back to the plan, which must receive the appeal within 65 days of the date on its notice. A Notice of Medicare Non-Coverage means home health, skilled nursing, hospice or rehabilitation services are ending, and that one goes to an independent reviewer called the BFCC-QIO, run for Medicare by Acentra or Commence depending on the state, on a much shorter clock.

None of these reviewers is the facility that sent the notice. Medicare’s appeals guide says the people who decide an Original Medicare appeal are separate from the people who made the first decision. The quiet part is that the system gives the family the job of finding the right door, and the door is printed on the letter in small type rather than explained. If a level goes against your dad, the decision letter describes the next: an independent reconsideration (180 days to ask in Original Medicare), a hearing at the Office of Medicare Hearings and Appeals, the Medicare Appeals Council and federal court.

2. Your parent’s doctor supplies the evidence

Most appeals turn on records. Medicare tells families they can ask the provider for any information that would make the appeal stronger, and in a Medicare Advantage plan the treating doctor can ask the plan to reconsider a service your dad has not received yet without any representative paperwork.

One rule matters before the doctor writes anything. Denials of skilled care sometimes lean on the idea that a patient has stopped improving. CMS states, in its summary of the Jimmo settlement, that coverage of skilled nursing and skilled therapy in a skilled nursing facility, home health or outpatient therapy does not turn on a beneficiary’s potential for improvement but on the beneficiary’s need for skilled care. A denial that calls your dad ‘plateaued’ can land like a verdict on him, yet for a disease expected to progress, not improving is simply what the illness does, and under this rule it is no reason on its own to end skilled care. That distinction can be the center of the appeal. Whether your dad’s care counts as skilled care is a clinical judgment, which is exactly why the physician’s words belong in the file.

3. A SHIP counselor reads the letter with you

Every state runs a State Health Insurance Assistance Program, funded by the federal government, and its counselors work with people on Medicare, their families and their caregivers, including on appeals and complaints. There is no cost to use it.

In Texas the program is the Health Information, Counseling and Advocacy Program, a partnership between Texas Health and Human Services, Texas Legal Services Center and the Area Agencies on Aging, at 800-252-9240. Texas HHS lists help with Original Medicare complaints, rights and appeals, and says beneficiaries and their representatives are eligible. Other states’ offices are listed at shiphelp.org. A counselor explains the rules and options; working out what the denial does to the household budget sits outside that role.

4. Someone needs the authority to speak for your parent

This is where dementia changes the fight. Medicare will not discuss your dad’s records with you by default: the CMS form that lets 1-800-MEDICARE share his information with someone else states that, by law, Medicare needs his written permission first. Filing the appeal is a separate step. Medicare lets him appoint a representative, who can be a family member, friend, advocate, attorney or doctor, on form CMS-1696 or in a written request, and that appointment is valid for one year from the date both people sign it.

Both forms assume your dad can still sign. When he cannot, the federal appeal rules recognize an authorized representative, meaning someone authorized under state or other applicable law to act on his behalf, and Medicare’s disclosure form asks a person signing as a personal representative to attach proof, such as a power of attorney. Whether the document your family already holds reaches that far is a question for the attorney who drafted it or one licensed in your state. It is also one more reason the window for a parent with dementia to sign legal documents matters long before any denial arrives.

5. Legal help, for when the appeal climbs

Medicare built the early levels for families to file themselves. Legal help matters more when the case heads to a hearing at the Office of Medicare Hearings and Appeals, when a great deal of care is at stake, or when the denial is tangled up with a facility’s conduct or a family dispute over who has authority to act.

Texas has a useful middle step. Texas Legal Services Center’s Legal Hotline for Texans gives counsel and advice on Medicaid, Medicare and long-term care at no charge, open to all callers on those topics, at 800-622-2520, option 3. Its attorneys advise only; they cannot draft documents, negotiate with third parties or go to court. For representation, the National Academy of Elder Law Attorneys keeps a find-a-lawyer directory, and her guide to whether you need an elder law attorney and how they charge explains what to ask before you hire one.

6. A dementia caregiving strategist reads the denial against the money and the timeline

Each person above owns one document or one step. What nobody on that list is asked to do is the arithmetic of the meantime: what the care costs while the appeal is pending, who pays it, how long the household can carry it, and what happens if the disease moves faster than the appeal does. That is the work Jessica does. She describes reading a denial the way she once read audit findings across her years in finance, and as a Certified Dementia Practitioner she knows the stage of the disease changes what the next six months of care will need.

Her approach holds two clocks at once: the appeal deadline printed on the letter and the capacity clock that runs on your dad’s diagnosis. A family can win an appeal and still miss the window to get his powers of attorney signed, or spend months contesting a denial for care Medicare was never going to cover. For when the system keeps saying no, she teaches an escalation ladder on her Advocacy and System Navigation page that climbs from a supervisor and a formal complaint to the ombudsman or insurance commissioner, patient advocacy organizations, local media where it fits and, finally, an elder law attorney.

7. When the denial follows the rules, the fight becomes a funding plan

Some denials are correct under the rules. Medicare says it does not pay for long-term care, also called custodial care: help with everyday tasks like dressing, bathing and using the bathroom, the kind a parent with dementia needs every day. No appeal changes that line. Her guide to whether Medicare pays for memory care or assisted living shows where it sits. When a letter is enforcing that line, the useful work moves from the appeal to the plan: which sources pay next, in what order, and what has to be signed while your dad still can.

What to bring to the first conversation

Whoever you call first, the conversation moves faster with the same short stack on the table. Jessica works with families nationwide through virtual coaching, with in-person roots in Austin and Central Texas, and this stack lets a first conversation start with your dad’s situation instead of the search for paperwork.

• The denial or non-coverage notice, with the date it arrived and the deadline circled
• Your dad’s Medicare card or plan card, so it is clear whether this is Original Medicare or a Medicare Advantage plan
• Any power of attorney, guardianship order, signed CMS-1696 or CMS-10106 already on file
• The care plan or facility contract, and what the denied care costs each week
• The diagnosis, its date and the treating doctor’s contact details

When the letter still does not make sense

If the notice still does not parse, the deadline is close, or the family cannot agree who handles which part, that is where Jessica starts with a family: the deadline on the letter first, then what the care costs while the appeal runs, then which professional owns each part. A discovery video call with her works that out, and whether ongoing monthly coaching fits your family. You do not have to master every appeal level tonight; you need the deadline on the page and the right person on each part.

Frequently Asked Questions

Q: Who should I call first about a Medicare denial for a parent with dementia?

A: It depends on the notice. If it is a Notice of Medicare Non-Coverage, the call that protects coverage goes to the BFCC-QIO named on it, by noon the day before the end date. If it is a Medicare Summary Notice or a Medicare Advantage denial, the deadline is longer, so a SHIP counselor can explain the letter first while the doctor’s office pulls records. Find the deadline on the page before anything else.

Q: Can I appeal for my dad if he can no longer sign Medicare forms?

A: Federal appeal rules recognize an authorized representative, someone authorized under state or other applicable law to act for the beneficiary. Medicare’s disclosure form asks a personal representative to attach proof, such as a power of attorney. Whether a particular document covers Medicare appeals depends on its wording and your state’s law, so that is a question for an attorney.

Q: Do I need a lawyer to appeal a Medicare denial?

A: Not at the start. Medicare designed the early levels for beneficiaries and families, and a representative can be a family member. A SHIP counselor can explain the letter, and in Texas the Legal Hotline for Texans gives advice on Medicare at no charge. Representation tends to matter more at the hearing level, when a large amount of care is at stake, or when there is a dispute about who has authority to act.

Q: What does a dementia caregiving strategist do in a Medicare appeal?

A: Jessica Lizel Cannon reads the denial alongside the care contract and the dementia timeline. She works out what the care costs while the appeal is pending, which deadline is more urgent, the appeal or the window to sign documents, and which professional should handle each part. She does not file the appeal in place of the family or replace the doctor, SHIP or an attorney; she helps the family sequence them.

Citations

• Medicare.gov, Appeals. Confirms that the appeals process varies by type of coverage, that there are generally five levels, and that you can ask your provider for information to strengthen an appeal. https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals
• Medicare.gov, Fast appeals. Source for the BFCC-QIO’s role, the noon-the-day-before deadline, the hospital discharge deadline and the decision times in the table. https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/fast-appeals
• Medicare.gov, Appeals in Original Medicare. Confirms that a redetermination must be filed by the date in the Medicare Summary Notice, the 60-day decision time, the 180 days to request a second-level appeal and the later levels. https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/original-medicare
• Medicare.gov, Appeals in Medicare health plans. Confirms the 65-day deadline for a Medicare Advantage reconsideration and the 72-hour expedited decision. https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans
• Medicare Appeals (CMS Product No. 11525, April 2026). Medicare’s official appeals guide: who can be a representative, the treating doctor’s role in Medicare Advantage, and the separation between the original decision and the reviewers. https://www.medicare.gov/publications/11525-medicare-appeals.pdf
• CMS Form CMS-1696, Appointment of Representative. States that an appointment of a representative is valid for one year from the date both people sign. https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms1696.pdf
• CMS Form CMS-10106, Authorization to Disclose Personal Health Information. States that 1-800-MEDICARE needs written permission before sharing information with someone else, and that a personal representative attaches proof such as a power of attorney. https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms10106.pdf
• 42 CFR 405.902, Definitions (Cornell Legal Information Institute). Defines an authorized representative as an individual authorized under State or other applicable law to act on behalf of a beneficiary in the appeal. https://www.law.cornell.edu/cfr/text/42/405.902
• CMS, Jimmo Settlement. Confirms that coverage of skilled nursing and therapy in SNF, home health and outpatient therapy turns on the need for skilled care, not the potential for improvement. https://www.cms.gov/medicare/settlements/jimmo
• Texas Health and Human Services, Medicare. Describes the Texas Health Information, Counseling and Advocacy Program, its partners, its help with Medicare appeals and its number, 800-252-9240. https://www.hhs.texas.gov/services/health/medicare
• Texas Legal Services Center, Senior Care, Retirement, and Estate Planning. Describes the Legal Hotline for Texans: counsel and advice on Medicaid, Medicare and long-term care for all callers, advice only. https://www.tlsc.org/seniors
• Medicare.gov, Long-term care. States that Medicare does not pay for long-term care, also called custodial care, such as help with dressing, bathing and using the bathroom. https://www.medicare.gov/coverage/long-term-care
• Medicare.gov, Get help with your rights and protections. States that the BFCC-QIO is administered for Medicare by Commence or Acentra, depending on the state. https://www.medicare.gov/basics/your-medicare-rights/get-help-with-your-rights-protections
• CMS Form CMS-20027, Medicare Redetermination Request. The request form asks for a reason for late filing if the initial determination notice arrived more than 120 days earlier. https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf
• National Academy of Elder Law Attorneys, Find a Lawyer. NAELA’s directory of elder law attorneys, searchable by zip code. https://www.naela.org/findlawyer
• SHIP National Technical Assistance Center, About SHIPs. Confirms SHIP services carry no cost and include help making an appeal or complaint, for beneficiaries, families and caregivers. https://www.shiphelp.org/what-we-do/about-ships/

Related reading

• What Do I Do When Medicare Won’t Pay?
• Does Medicare or Medicaid Cover In-Home Care?
• The Step-by-Step Checklist for Appealing a Hospice Discharge or Medicare Denial
• How reactive caregiving can cost families up to $750K, and what proactive planning saves
• Advocacy and System Navigation for Caregivers
• The Proactive Caregiver Method

About this article. Jessica Cannon is a CPA with 28 years of financial experience and a Certified Dementia Practitioner. She provides financial coaching, not legal or medical services. This article is general information about how these systems work, not advice about your situation, and it is not a substitute for the advice of an attorney. It is not medical advice, and it is not individualized tax or financial advice.

For the legal instruments themselves, including wills, powers of attorney and guardianship, you will need a licensed attorney in your own state. Medicaid and long-term care rules also differ by state and change over time, so any Texas detail here is an example rather than a rule that will apply to you.