Medicare denies claims and coverage requests more often than most people realize — and a surprising percentage of those denials are overturned on appeal. If Medicare or your Medicare plan has refused to cover a service, drug, or equipment you need, you have the right to appeal. The appeals process is formal, has deadlines, and takes persistence — but it works.
Why Medicare denials happen
Claims can be denied for many reasons, not all of them final:
- The service wasn’t considered “medically necessary” by the plan or Medicare’s review contractor
- The claim was filed incorrectly (wrong billing code, missing information)
- The provider isn’t in your plan’s network (Medicare Advantage)
- A prior authorization was required but not obtained
- Medicare’s coverage rules weren’t met (e.g., the 3-day hospital stay rule for SNF coverage)
- The drug isn’t on your plan’s formulary or requires step therapy
Some denials are legitimate coverage limits. Others are errors — billing mistakes, incorrect documentation, or plan decisions that don’t hold up under review. You won’t know which until you appeal.
The five levels of Medicare appeal
Original Medicare and Medicare Advantage have similar but slightly different appeal processes. Here’s the general structure:
Level 1: Redetermination
For Original Medicare: file a redetermination request with the Medicare Administrative Contractor (MAC) that processed the original claim. You have 120 days from receiving the claim denial to request a redetermination. The MAC has 60 days to respond.
For Medicare Advantage: request an organization determination review from your plan. The plan has 60 days for standard requests, or 72 hours for expedited (urgent) requests.
Level 2: Reconsideration
If Level 1 is denied, request reconsideration. For Original Medicare, this goes to a Qualified Independent Contractor (QIC) — an independent reviewer. You have 180 days from the Level 1 decision. The QIC has 60 days to respond.
For Medicare Advantage, reconsideration is handled by an Independent Review Entity (IRE).
Level 3: ALJ Hearing
If the amount in dispute is at least $180 (2025 threshold), you can request a hearing before an Administrative Law Judge (ALJ). You have 60 days from the Level 2 decision. ALJ hearings can be done in person, by phone, or by video. This is often the first level where an independent decision-maker hears your case directly.
Level 4: Medicare Appeals Council
If the ALJ rules against you, you can appeal to the Medicare Appeals Council within 60 days of the ALJ decision. The Council reviews the record and can uphold, reverse, or send the case back to the ALJ.
Level 5: Federal District Court
If the amount in dispute is at least $1,870 (2025) and you’ve exhausted the administrative process, you can file a lawsuit in federal district court. This is rare for most Medicare disputes but remains available.
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How to file an appeal
Get the denial in writing
You should receive a written notice explaining why the claim was denied and how to appeal. For Original Medicare claims, this comes on an Explanation of Benefits (EOB) or a Medicare Summary Notice (MSN), which Medicare mails quarterly. For Medicare Advantage, the denial notice is called a Notice of Denial of Medical Coverage or similar.
If you haven’t received a written notice, request one. You need the denial reason and denial code to mount a strong appeal.
Gather supporting documentation
The stronger your documentation, the better your odds. Gather:
- Your doctor’s letter of medical necessity — this is the most important document
- Relevant medical records, test results, and treatment history
- Published clinical guidelines supporting the treatment
- Any prior authorization approvals or correspondence
- The specific Medicare coverage rule or Local Coverage Determination (LCD) that was cited in the denial
Write a clear appeal letter
Your appeal letter should state: what was denied, why you believe it should be covered, and reference the supporting documentation. Be specific. Reference the denial date, claim number, and the exact service or drug denied. Ask your doctor to write a supporting letter — physician advocacy is one of the most effective factors in successful appeals.
Meet the deadlines
Appeal deadlines are firm. Level 1 gives you 120 days from the denial (for Original Medicare) or 60 days (Medicare Advantage). Missing the deadline generally closes that level of appeal. Calendar the deadline immediately when you receive a denial.
Expedited appeals for urgent situations
If you need a service urgently — for example, your Medicare Advantage plan has denied a service you need immediately, or you’re about to be discharged from a hospital and disagree — you can request an expedited appeal. Plans must respond within 72 hours for expedited requests. For hospital discharge disputes, you can request a fast appeal from your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) before you leave.
Free help with appeals
You don’t have to navigate appeals alone. Two free resources:
- SHIP (State Health Insurance Assistance Program) — free Medicare counseling from trained volunteers. They can help you understand the process and review your appeal materials. Find yours at shiphelp.org.
- 1-800-MEDICARE (1-800-633-4227) — can explain denial reasons and direct you to the right appeals process.
For complex or high-value disputes, a Medicare attorney or patient advocate may be worth consulting. Some work on contingency for large claims.
How often do appeals succeed?
More often than most people expect. Studies of Medicare Advantage appeals have found that a large percentage of denials that are appealed — particularly at the ALJ level — are overturned in the patient’s favor. Many initial denials are automated and don’t reflect a full review of the medical record. A well-documented appeal with strong physician support has a real chance of success.
Even if your appeal at Level 1 fails, continuing to Level 2 (independent review) and Level 3 (ALJ hearing) significantly improves the odds. The process takes time, but persistence matters.
Bottom line
A Medicare denial is not the end of the road. The appeals process exists specifically because denials are sometimes wrong. If you receive a denial for a service or drug you genuinely need, get the written notice, gather documentation, involve your doctor, and file the appeal before the deadline. Free help is available through SHIP and 1-800-MEDICARE. The process is worth using.
🆓 Have questions about a Medicare denial or coverage dispute?
Our partner Chapter Medicare offers free guidance from licensed advisors who can help you understand your rights and options.
📞 Call 615-639-1937 | 🔗 askchapter.org/money
ALWAYS FREE. No obligation.
Disclosure: We may receive a referral from Chapter if you choose to use their service. Chapter is a licensed health insurance agency and is not affiliated with or endorsed by Medicare or any government agency.
Further Reading
- Medicare Costs and Premiums
- Medicare Advantage vs. Original Medicare
- Medicare Advantage: Pros and Cons
- How to Choose a Medicare Plan
- Medicare Special Enrollment Periods
- Free Medicare Help
This article is for general educational purposes only and does not constitute insurance or financial advice. Visit medicare.gov or contact 1-800-MEDICARE, or consult a licensed advisor for guidance specific to your situation.