Insurance Appeals: When to Hire an Advocate
A client emailed me a denial letter last spring with one line in the subject: "Do I need to hire somebody?" The chair was a custom ultralight manual, the denial was three sentences long, and she'd already spent $0 and about eleven hours of her own time on it.
My answer was no — not yet. She won at the first level six weeks later with a two-page letter and one document her therapist already had on file.
But sometimes the answer is yes, and waiting too long to hire help is how people lose. Here's how I think about the line between the two.
First, know which ladder you're on
The deadlines and the odds are different depending on who denied you, and most people don't know which system they're in.
Original Medicare. Five levels. Level 1 is a redetermination by the DME MAC, filed within 120 days of the initial determination, with no minimum dollar amount, and generally decided within 60 days. Level 2 is reconsideration by a Qualified Independent Contractor, filed within 180 days — and evidence not submitted at this level can be excluded later without good cause. Read that last part twice. Level 3 is an ALJ hearing, filed within 60 days of the QIC decision, with a $200 amount-in-controversy threshold for 2026.
The ALJ stage used to be where cases went to die. Average processing times once ran past 1,400 days; OMHA's published data for fiscal year 2026 puts the average at roughly 69 days. That changes the math on whether a long fight is worth it.
Medicare Advantage. Faster clocks, and they cut both ways. Standard prior authorization decisions must come within 7 days and expedited decisions within 72 hours under CMS-0057-F, and a missed deadline counts as an adverse determination you can appeal. All MA plans must accept appeals filed within at least 60 days of the denial notice. The good news: if the plan upholds its denial, the case transfers automatically to an independent review entity — you don't have to request level 2.
Commercial/employer plans. Typically 180 days to file an internal appeal, then 4 months after the final internal denial to request external review by an independent organization — and for non-grandfathered ACA plans, that external decision is binding on the insurer. External review is the most underused tool I see. Use it.
When you don't need to pay anybody
Most first-level DME denials I see are paperwork failures, not medical disagreements. A missing face-to-face note. A standard written order with the wrong date. A therapist evaluation that describes the chair but never says plainly why a lighter, adjustable frame is medically necessary in the home.
Fix the document, refile, win. You don't need a professional for that — you need your supplier and your therapist to do their jobs, and you need to be the one making sure they do.
Before you spend money, use the free help: your State Health Insurance Assistance Program offers free, impartial counseling and isn't affiliated with any insurance company. State insurance departments handle complaints on commercial plans. Both cost nothing.
When to hire someone
I'd start paying when at least two of these are true:
- You lost level 1 and the denial is substantive, not clerical. If they're arguing your chair isn't medically necessary — not that a form was missing — you're in a clinical argument now.
- You're heading into QIC reconsideration. This is the evidence gate. Everything you want an ALJ to ever see needs to be in that file.
- Your supplier has gone quiet. A supplier that stops returning calls after a denial has already made its decision about your case.
- The dollars justify it. A $7,000 custom ultralight with a $2,000 upgrade dispute is worth fighting for. A $300 accessory usually isn't.
What it costs, honestly
Private-pay independent advocates typically run $100–$500 an hour depending on credentials and complexity, with some newer advocates starting around $70. A reconsideration-level case is often 5–15 hours. So figure $700 to $4,000, with no guarantee.
That's the tradeoff nobody states plainly. You may spend $1,500 and still lose. Ask any advocate three things before you sign: how many DME denials they've personally handled, what their outcomes were, and whether they'll cap the hours. If they won't answer concretely, keep looking.
One more thing — the strongest appeal document is almost always a letter from your treating clinician that connects your specific body and your specific day to the specific chair. Not a catalog page. An advocate can organize that. They can't create it.
Ready for a Chair That Actually Fits?
The best appeal is the one you never have to file — and that starts with documentation that matches the chair from day one.
I work directly with clients to specify and order custom ultra-lightweight wheelchairs — no middlemen, no upsells, just the chair that fits your life.
Get started at wheelchair.direct — answer a few questions and I'll reach out personally.