How to Appeal a Medicare Denial: Step-by-Step for 2026

If Medicare denied your claim, you have the right to appeal. You must file your first appeal within 120 days of receiving your Medicare Summary Notice. According to CMS data, roughly half of all first-level appeals result in the denial being overturned. There are 5 levels of appeal, and you can escalate all the way to federal court if needed.

You open the envelope and there it is - "Medicare has determined this service is not covered." Your stomach drops. We see this reaction every week, and here is what we tell every single patient: that letter is not the final word. Not even close.

Over 200 million Medicare claims get denied every year, but only 11% of patients ever fight back. The ones who do? They win roughly 80% of the time. Those numbers should make you angry - and then they should make you pick up a pen.

Let us walk through exactly how the process works, what deadlines you need to hit, and what to include in your appeal.

Why Do Medicare Claims Get Denied?

Before you file anything, take a breath and figure out why they said no. Most denials fall into one of these categories - and some of them are just paperwork mistakes that your doctor's office can fix without a formal appeal:

• Not medically necessary: Medicare decided the service or item was not needed for your condition
• Coding errors: The doctor's office or hospital submitted the wrong billing code
• Coverage limitations: The service is not covered under your plan (see what Part A and Part B cover), or you have used up your allowed benefit
• Missing prior authorization: The service needed pre-approval that was not obtained
• Out-of-network provider: You received care from a provider not in your plan's network (Medicare Advantage)
• Duplicate claim: A claim was submitted twice for the same service
• Timely filing: The provider did not submit the claim within Medicare's deadline

Here is a tip we always share first: call your doctor's billing office before you do anything else. Coding errors and duplicate claims can often be fixed with a simple phone call - no appeal needed. If that does not resolve it, then you move to the formal appeals process.

How to Read Your Denial Notice

That piece of paper you got in the mail? It is called a Medicare Summary Notice (MSN), and it comes every 3 months. If you have a Medicare Advantage plan, yours is called an Explanation of Benefits (EOB). Either way, do not throw it out. You need it.

Here is what to look for on your notice:

• The specific service or item that was denied
• The reason code and explanation for the denial
• The deadline to file your appeal
• Instructions on where to send your appeal

Put this notice somewhere safe - you will need it for your appeal letter. And if those codes and charges look like a foreign language, you are not alone. A patient advocate can help you decode it.

The 5 Levels of Medicare Appeals

Here is how the system works in your favor - there are five levels, and each one is reviewed by a completely different, independent group of people. Fresh eyes every time. If Level 1 says no, Level 2 might say yes. We have seen it happen hundreds of times.

Level 1: Redetermination

Deadline: 120 days from the date on your MSN

Decision timeline: 60 days for Original Medicare; 30 days for Medicare Advantage pre-service denials

Who reviews it: A Medicare Administrative Contractor, which is the company that processed your original claim

This is your first and most important step. You are asking the same organization that denied your claim to take another look, but a different person reviews it. Here is what to include:

1. Write a clear appeal letter stating you are requesting a redetermination
2. Include your name, Medicare number, and the date of the service that was denied
3. Reference the specific claim number from your MSN
4. Explain why you believe the service should be covered, in plain language
5. Attach a letter from your doctor explaining the medical necessity of the service
6. Include any supporting documents such as medical records, test results, or treatment plans
7. Make copies of everything before you send it

A letter from your doctor is often the single most important piece of evidence. If your claim was denied as "not medically necessary," your doctor can explain in clinical terms why the service was required for your specific condition.

According to CMS data, roughly half of Level 1 appeals result in a full or partial reversal of the denial. Those are good odds, and they improve when you include strong supporting documentation.

Level 2: Reconsideration by a Qualified Independent Contractor

Deadline: 180 days from the date of your Level 1 decision

Decision timeline: 60 days for Original Medicare; 30 days for Medicare Advantage

Who reviews it: A Qualified Independent Contractor, or QIC, which is completely independent from Medicare

If your Level 1 appeal is denied, you can request a reconsideration. This time, an organization that has no connection to the original decision reviews your case from scratch. You can submit additional evidence at this stage, and you should if you have it.

The instructions for filing Level 2 will be included in your Level 1 denial letter. Follow them carefully and include all documentation from your Level 1 appeal plus anything new.

Level 3: Hearing Before an Administrative Law Judge

Deadline: 60 days from the date of your Level 2 decision

Minimum amount in dispute: $190 for 2026

Decision timeline: 90 days

Who reviews it: An Administrative Law Judge, or ALJ, at the Office of Medicare Hearings and Appeals

At Level 3, you get a hearing where you can present your case, often by phone or video conference. The amount in dispute must meet the minimum threshold of $190 for 2026. You can combine multiple denied claims to meet this amount.

This is where having an advocate or representative can make a real difference. You have the right to bring someone to speak on your behalf, whether that is a family member, a patient advocate, or an attorney. If you feel overwhelmed by the process, learning about patient self-advocacy can help you prepare to present your case effectively.

Level 4: Review by the Medicare Appeals Council

Deadline: 60 days from the date of your Level 3 decision

Decision timeline: 90 days

Who reviews it: The Medicare Appeals Council, part of the Departmental Appeals Board

The Appeals Council can review, modify, or reverse the ALJ decision. They can also send your case back to the ALJ for a new hearing. This level is more of a legal review than a new hearing, so new evidence is generally only accepted if it is relevant and was not available earlier.

Level 5: Federal District Court

Deadline: 60 days from the date of your Level 4 decision

Minimum amount in dispute: $1,850 for 2026

Who reviews it: A federal judge

This is the final level. Very few appeals make it here, but the option exists. You will likely need legal representation at this stage. The amount in dispute must be at least $1,900.

Appeal Deadlines at a Glance

Tips to Strengthen Your Appeal

Whether you are filing at Level 1 or escalating further, these steps give you the best chance of a favorable outcome:

1. Act quickly. Do not wait until the deadline approaches. The sooner you file, the sooner you get a decision, and the more time you have if you need to escalate.
2. Get your doctor involved early. Ask your doctor to write a detailed letter of medical necessity. The letter should reference your specific diagnosis, explain why the denied service was needed, and cite any clinical guidelines that support the treatment.
3. Keep detailed records. Save copies of every document you send and receive. Note the dates of phone calls, the names of people you speak with, and what was discussed.
4. Be specific in your appeal letter. Reference the exact claim number, date of service, and denial reason. State clearly what outcome you are requesting.
5. Include all supporting evidence. Medical records, lab results, prescription history, letters from specialists, and photos if relevant. More documentation is better than less.
6. Request an expedited review if your health is at risk. If delaying the service could seriously harm your health, you can ask for a fast-track decision. Medicare Advantage plans must respond to expedited requests within 72 hours.

What If Your Appeal Is for a Medicare Advantage Plan?

The appeals process for Medicare Advantage plans follows the same five levels, but with some differences in timing and process:

• Level 1 decisions come faster, within 30 days for post-service claims and 72 hours for pre-service claims
• Your plan must continue providing coverage during the appeal in some situations, particularly if you are currently receiving the service and your plan is trying to stop it
• If your plan does not respond by the deadline, your case automatically moves to Level 2

You still have the same right to escalate through all five levels.

When to Get Help With Your Appeal

You do not have to go through this process alone. Free help is available from several sources:

• State Health Insurance Assistance Program (SHIP): Every state has a SHIP that provides free Medicare counseling and can help you with appeals
• Your state's Medicare ombudsman: They investigate complaints and can advocate on your behalf
• Legal aid organizations: If your case reaches Level 3 or higher, legal aid may be able to represent you at no cost
• Patient advocates: Professional advocates can review your case, help write your appeal, and represent you at hearings

If you are managing an ongoing health condition and dealing with repeated denials, coordinating your care and paperwork together can reduce the chances of future denials. Our care coordination services can help you stay organized and proactive.

Common Mistakes to Avoid

A few errors can weaken your appeal or cause it to be dismissed entirely:

• Missing the deadline. If you file even one day late, your appeal may be rejected. Mark the deadline on your calendar the day you receive your denial.
• Not including a doctor's letter. A letter of medical necessity from your treating physician is the strongest piece of evidence you can include.
• Using vague language. "I need this service" is not as effective as "This service is medically necessary because my diagnosis of [condition] requires [specific treatment] as supported by [clinical guideline]."
• Giving up after Level 1. Many people stop after the first denial is upheld. But each level brings a fresh, independent review. The odds of success increase as you escalate because each reviewer brings a new perspective.
• Not keeping copies. If your appeal gets lost in the mail, you need to be able to prove what you sent and when.

Documents You Need for Your Appeal

A complete appeal packet dramatically increases your chances of success. Gather these documents before you file.

Pro tip: Call your doctor's office and specifically ask for a "letter of medical necessity." Do not assume your medical records alone will be enough. The letter should explain in plain language why the denied service is medically necessary for your specific condition.

Sample Medicare Appeal Letter Template

Use this template as a starting point for your Level 1 appeal. Customize every section with your specific details. A personalized letter is significantly more effective than a generic one.

Important: Send your appeal by certified mail with return receipt requested. This gives you proof of delivery and the date received. Keep copies of everything you send. The MAC must acknowledge receipt within 5 business days.

Original Medicare vs. Medicare Advantage: Different Appeal Processes

The appeals process differs depending on whether you have Original Medicare or a Medicare Advantage plan.

Medicare Advantage members: You have a shorter deadline (60 days vs. 120 days) but also a faster decision timeline. If your situation is urgent, request an expedited appeal - your plan must decide within 72 hours.

Frequently Asked Questions

How long do I have to appeal a Medicare denial?

You have 120 days from the date on your Medicare Summary Notice to file your first appeal (Level 1 Redetermination). For Medicare Advantage plans, the deadline is 60 days from the date on your Explanation of Benefits. Always check the specific deadline printed on your denial notice, as some situations may have different timeframes.

Does it cost anything to file a Medicare appeal?

No. There is no fee to file an appeal at any level. The only financial threshold is the minimum amount in dispute required for Level 3 ($190 in 2026) and Level 5 ($1,900 in 2026). These are not fees you pay - they refer to the dollar amount of the denied claim.

Can I still receive the denied service while my appeal is being reviewed?

In some cases, yes. If your Medicare Advantage plan is stopping a service you currently receive, you can request continued coverage during the appeal by responding within 10 days. If the appeal is ultimately denied, you may owe for services received during the appeal period.

What is the success rate for Medicare appeals?

Approximately half of first-level appeals result in the original denial being fully or partially overturned. Success rates vary depending on the reason for denial and the strength of supporting documentation. Appeals with a detailed letter of medical necessity from the treating physician have a significantly higher success rate than those filed without one.

Can someone else file an appeal on my behalf?

Yes. You can designate a representative to act on your behalf at any level of the appeals process. This can be a family member, friend, doctor, attorney, or patient advocate. You will need to complete an Appointment of Representative form (CMS-1696) and include it with your appeal. Your representative can file paperwork, attend hearings, and make decisions on your behalf.

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