How to Appeal a Medicare Coverage Denial

Getting a Medicare coverage denial can feel like a dead end, but it is actually just the beginning of a process you have the right to use. Medicare denials are appealed successfully every day, and for many types of claims, appealing is genuinely worth the effort. Here is how the process works.

Why Medicare Denies Claims

Medicare denials happen for a variety of reasons, not all of them because the care was inappropriate or unnecessary. Common reasons include: billing errors or incorrect codes submitted by the provider, insufficient documentation of medical necessity, the service was provided by an out-of-network provider, the service requires prior authorization that was not obtained, or Medicare determined the care was not "reasonable and necessary" for your condition.

Some of these reasons -- particularly documentation and billing errors -- are fairly easy to address on appeal. Others require more substantive documentation from your doctor.

Level 1: Redetermination

The first level of appeal is called a redetermination. You request that a Medicare Administrative Contractor review the original decision. You have 120 days from the date you received the initial denial to file this appeal.

To file, you can write to the address on your Medicare Summary Notice (the explanation of benefits Medicare sends after a claim is processed), use Form CMS-20027 for Part B redeterminations, or call 1-800-MEDICARE to request it. Include a written explanation of why you believe the service should be covered and any supporting documentation from your doctor.

The contractor must respond within 60 days. Redeterminations reverse the original denial a meaningful percentage of the time, particularly when additional documentation is provided.

Level 2: Reconsideration

If the redetermination goes against you, you can escalate to a reconsideration by a Qualified Independent Contractor -- an organization that is independent from both Medicare and the original contractor. You have 180 days to file after receiving the redetermination decision.

This level requires submitting additional documentation and a written explanation of your case. Your doctor's support is critical here -- a letter from your physician explaining the medical necessity of the denied service significantly strengthens the appeal.

Level 3: Administrative Law Judge Hearing

If you still disagree after reconsideration, you can request a hearing before an Administrative Law Judge (ALJ) -- but only if the amount in dispute is at least $180 (in 2026). You have 60 days to file from the date of the reconsideration decision.

This is a formal hearing process. You can present your case in person, by phone, or in writing. Having a patient advocate or attorney who specializes in Medicare appeals can be helpful at this stage. ALJ hearings result in favorable decisions for claimants in a significant percentage of cases.

Levels 4 and 5: Further Appeals

If the ALJ rules against you, you can appeal to the Medicare Appeals Council and ultimately to federal district court. These higher levels are generally warranted only for large amounts in dispute or cases with broader policy implications.

Getting Help With Your Appeal

You do not have to navigate this alone. Your State Health Insurance Assistance Program (SHIP) offers free counseling and can help you file appeals. Patient advocates at your hospital or clinic can assist with documentation. For significant denials, some attorneys handle Medicare appeals on a contingency basis.

The Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) also help Medicare patients with certain types of appeals, particularly around hospital discharge and care transitions.