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Medicare Appeals: What to Do When Coverage Is Denied

A Medicare denial can feel confusing and urgent. You may be facing a medical need, an unexpected bill, or a notice saying that services will stop. You may also be unsure where to begin.

The good news is that Medicare gives you a formal process to challenge many coverage and payment decisions. The correct steps depend on the type of Medicare coverage you have and the notice you received.

This is Part 2 of our three-part series on Medicare and Medicaid planning in New York and Florida. In Part 1, we discussed Medicaid and Medicare planning. Here, we explain Medicare appeals in plain language.

Important: Medicare appeals are separate from Medicaid eligibility disputes. They are also different from Medicare grievances, which generally concern service or quality problems rather than a coverage or payment decision.

First, identify your Medicare coverage

Before filing an appeal, determine which program made the decision.

Original Medicare, Parts A and B

Original Medicare is the federal fee-for-service program. Medicare makes coverage and payment decisions through its claims-processing contractors.

You may receive a Medicare Summary Notice, or MSN, showing that Medicare:

Medicare Advantage, Part C

Medicare Advantage plans are offered by private insurance companies approved by Medicare. Your plan generally handles Part A and Part B benefits. Many plans also include prescription drug coverage.

For Medicare Advantage, the initial coverage decision is called an organization determination. This may concern whether the plan will:

Medicare Part D

Part D provides prescription drug coverage through private Medicare-approved drug plans.

The initial decision is generally called a coverage determination. It may involve:

The notice from your plan should explain your appeal rights. Read it carefully. Do not rely only on a general deadline you find online. Your notice and coverage type control the process.

The five levels for Original Medicare

Original Medicare generally has five levels of appeal. Each decision notice should tell you how to move to the next level.

Level 1: Redetermination by the Medicare Administrative Contractor

A redetermination is the first formal review of an Original Medicare claim denial.

Start with your MSN or other Medicare notice. It should identify the deadline and the address for filing. The Medicare.gov instructions state that the appeal deadline appears on the MSN. The deadline is often tied to the date you received the notice.

You can generally file by:

Include:

Ask your provider or supplier for documents that may help explain the medical need.

Level 2: Reconsideration by a Qualified Independent Contractor

If the redetermination is unfavorable, you may request a reconsideration by a Qualified Independent Contractor, or QIC.

The QIC did not participate in the first-level decision. The reconsideration request generally must be filed within 180 days after receiving the redetermination decision, but always follow the instructions in your notice.

You may use CMS Form 20033, Medicare Reconsideration Request. Explain why you disagree with the first decision. Include the redetermination notice and any additional evidence.

Level 3: Administrative Law Judge review

If the QIC decision is unfavorable, you may request review by an Administrative Law Judge, or ALJ, through the Office of Medicare Hearings and Appeals, known as OMHA.

The request generally must be filed within 60 days after receiving the QIC decision. For appeals filed in 2026, the amount remaining in controversy generally must meet a minimum threshold of $200.

An ALJ review may involve:

Level 4: Medicare Appeals Council review

If you disagree with the ALJ decision, you may ask the Medicare Appeals Council to review it.

The request generally must be filed within 60 days after receiving the ALJ decision. Follow the directions in that decision. You may use the Request for Review of an ALJ Medicare Decision or Dismissal form.

Level 5: Federal district court review

Federal court review may be available after a Medicare Appeals Council decision or failure to issue a timely decision.

For appeals filed in 2026, the amount remaining in controversy generally must meet a minimum threshold of $1,960. The request generally must be filed within 60 days after receiving the Appeals Council decision.

Federal court review is a formal legal proceeding. Consider obtaining advice from a qualified attorney before taking this step.

Close-up of a Medicare appeal packet with medical records, provider support, a calendar, and a pen

How Medicare Advantage appeals work

Medicare Advantage uses a plan-based process for the first appeal levels.

Step 1: Organization determination

You, your representative, or your doctor may ask the plan for an organization determination. The plan must provide information about whether it will cover or pay for the service, item, or drug.

If the plan denies the request, the denial notice should explain how to appeal.

Step 2: Reconsideration by the plan

The first appeal is generally called a health plan reconsideration. You, your representative, or your provider may file it.

The request generally must be filed within 65 days from the date on the initial denial notice. If you file late, explain the reason.

For a service you have not yet received, your doctor may be able to request reconsideration on your behalf.

If the plan upholds its denial, the appeal is generally forwarded automatically to an Independent Review Entity, or IRE, for the next level.

Step 3: Independent Review Entity

The IRE is an outside reviewer that contracts with Medicare. It reviews the plan’s decision and the appeal record.

If the IRE decision remains unfavorable, you may generally request ALJ review within 60 days. Later levels may include:

The notices at each level should provide the applicable deadline, instructions, and any amount-in-controversy requirement.

How Medicare Part D appeals work

Part D follows a similar five-level structure, but the terminology is different.

  1. Coverage determination: The plan makes the initial decision.
  2. Redetermination: You ask the Part D plan to review its denial.
  3. Reconsideration: An Independent Review Entity reviews the plan decision.
  4. Administrative Law Judge review: OMHA may review the case if requirements are met.
  5. Medicare Appeals Council and federal court review: Further review may be available.

A Part D redetermination generally must be requested within 65 days after the initial denial notice. If the plan upholds the denial, you generally have 60 days to request reconsideration by the Independent Review Entity.

For standard Part D appeals, the plan or reviewer generally has:

Your prescriber can provide a supporting statement, particularly when you are requesting an exception or disputing a medical necessity decision.

Standard appeals versus expedited appeals

A standard appeal follows the ordinary review schedule. An expedited, or fast, appeal is designed for situations where waiting could seriously jeopardize your health, your life, or your ability to regain maximum function.

For Medicare Advantage, typical plan response periods include:

For Part D, typical response periods include:

A plan may extend certain timeframes in limited situations. The plan should explain the reason and your rights if it takes an extension.

Original Medicare also has fast appeal procedures when a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice is ending services too soon. The notice may direct you to an independent Beneficiary and Family Centered Care Quality Improvement Organization, or BFCC-QIO.

Practical example: If a skilled nursing facility gives you a Notice of Medicare Non-Coverage, the notice may contain a short deadline for requesting a fast review. That deadline may be different from the deadline for appealing a past payment denial.

Always follow the notice for the specific service and coverage type. A fast appeal is not available for every payment dispute.

Preserve your appeal record

A strong administrative record begins with careful organization. Keep:

Keep the originals. Send copies unless the instructions require otherwise.

If a family member helps you, you may need to appoint that person as your representative. The notice should explain the process.

Appeals are not the same as grievances

An appeal challenges a coverage or payment decision. You use an appeal when the question is:

“Should Medicare or my plan cover this service, item, or drug, and what should it pay?”

A grievance generally concerns dissatisfaction that does not involve a specific coverage or payment determination. Examples may include:

Part 3 of this series will explain Medicare grievances, including when to file one, where to send it, and how grievances differ from appeals.

A Medicare appeal is also different from a Medicaid eligibility dispute. Medicaid disputes may involve income, assets, transfers, residency, application denials, or long-term care eligibility. Those issues follow separate rules. Learn more about our Elder Law and Medicaid Planning services.

Official Medicare resources

You can find current information and forms through:

SHIP provides free, personalized counseling. It may help you understand the notice, identify the correct appeal path, and locate forms or deadlines.

How we can help your family plan ahead

Medicare appeals concern current coverage or payment decisions. Estate planning addresses the broader legal and financial picture surrounding incapacity, long-term care, family responsibilities, and asset protection.

At Santopolo Law, PLLC, our Life & Legacy Planning® process helps families clarify their goals and coordinate important planning documents. This may be especially valuable for families in Erie County, New York, Florida’s Gulf Coast, and snowbirds who spend time between New York and Florida.

We serve families near Buffalo and Erie County, as well as Clearwater, St. Petersburg, Dunedin, Largo, Safety Harbor, Bradenton, and surrounding areas in Pinellas and Manatee Counties. We also offer virtual consultations for Florida residents.

If you have questions about your broader estate plan, contact us. A simple conversation can help you identify the next practical step.

General Information Disclaimer

This article provides general information only. It is not legal advice and is not a substitute for advice from a qualified attorney, Medicare counselor, or other appropriate professional. Medicare rules, laws, policies, notices, deadlines, and procedures may vary based on your coverage, the type of decision, and the facts of your situation. Reading this article does not create an attorney-client relationship with Santopolo Law, PLLC. No result, coverage decision, payment, or reversal is promised.

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