Medicare Appeals Decision Search (Part C & Part D)

With little (no?) fanfare, CMS published a decision database of summaries of the Qualified Independent Contractor’s (QIC) decisions on Part C and Part D appeals. Very little information is provided about the database. We don’t know the selection process for the decisions that are published or what percentage of the decision universe is represented by the 269,306 total results in the part C appeals decision database. The site does not indicate how far back the appeal decisions go, but by using one of the filter criteria I was able to determine that the oldest decision dates are from January 2, 2020. The most recent are from May 27, 2022, so it would appear that CMS plans to continue to publish recent decisions.

We have to assume these decisions represent Medicare Advantage plan denials where the payer was not contracted with the provider. The appeal process in that instance follows a path that advances an unsuccessful appeal automatically from the unfavorable redetermination decision from the Medicare Administrative Contractor (MAC) directly to the Independent Review Entity (the QIC.) The decisions could also represent appeals initiated by a patient, which would follow a similar path.

The decisions cover a wide variety of care and places of service. You will definitely want to use the filter functions to find the decisions of interest for you. After reviewing a couple of dozen inpatient admission decisions, I found that many of the decision summaries are quite vague and repetitive, not giving away any real tidbits of meaningful or insightful information. I did find a few decisions that provided a bit of insight into the QIC’s decision making, but the ability to find those types of cases is just a shot in the dark.

President at Association for Healthcare Denial and Appeal Management | | Website | + posts

Denise serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a Master’s degree in Management Information Systems from the University of Illinois, Springfield.

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.