When Medicare denies coverage for a health care service, supply, item, or drug, or says you own more than expected, you can appeal. If you receive a coverage rejection, get guidance from an elder law attorney and start the process right away.
As the United States Department of Health and Human Services explains, Medicare appeals generally have five levels. A case can eventually reach federal court if it meets the applicable requirements, including a minimum dollar amount. For 2026, that amount is $1,960.
Notifications of Coverage Denials
If Medicare has refused to cover care you already received, you should get a denial notice explaining the reason for the denial. The quarterly Medicare Summary Notice (MSN) for Original Medicare and the monthly Explanation of Benefits for Medicare Advantage can alert you to a denial in advance.
Read more about the reasons why Medicare denies coverage.
Appeal Process
Before appealing, review the denial notice, Medicare Summary Notice, or Explanation of Benefits and notify your health care provider. Medicare.gov recommends requesting information that helps your case from a doctor, health care provider, or supplier.
Your physician may appeal on your behalf or provide information to support your appea. You may also appeal yourself or appoint a representative. An attorney can represent you in your appeal, lending an understanding of the system’s complexities and ensuring you meet critical deadlines.
Identify the Appeal Deadline
It is crucial to be aware of your appeal deadline. Original Medicare beneficiaries can find the deadline on the MSN. Those with a Medicare health plan, such as Medicare Advantage, should review the plan’s initial denial notice and other plan materials. Generally, Medicare Advantage enrollees have 65 days from the date on the initial denial notice to request reconsideration. Follow the deadline and instructions on the notice.
If you miss the daedine, you may still be able to appeal by showing “good cause.” For example, illness, an accident, or another circumstances that prevented you from filing on time may support a good-cause explanation.
The first level of appeal depends on your coverage. If you have Original Medicare, you request a redetermination from the Medicare Administrative Contractor. If you have Medicare Advantage, you request a reconsideration from your plan. Follow the instructions on your denial notice, which will explain where and how to file.
Decision times vary depending on the type of appeal. For Medicare Advantage, a standard service reconsideration generally must be decided within 30 days, while an expedited appeal generally must be decided within 72 hours. For Original Medicare, the Medicare Administrative Contractor generally makes a first-level decision within 60 days. Follow the instructions and deadline in your denial notice or MSN.
If the Medicare Contractor or Medicare Advantage Plan denies your appeal, you can appeal to the next level: review by a Qualified Independent Contractor or an Independent Review Entity. After that, the case can escalate to the Office of Medicare Hearings and Appeals, then to the Medicare Appeals Council, before reaching federal court.
Expedited Decisions
If you have Medicare Advantage and waiting for a standard decision could seriously jeopardize your life, health,or ability to regain maximum function, you can ask for an expedited appeal. These appeals generally must be decided within 72 hours. For instance, if your health would severely decline without access to a medication or treatment, you could request an expedited appeal. Your doctor can also tell the plan that an expedited decision is necessary.
How Your Attorney and Doctor Can Help
As with an expedited appeal, your physician can play an essential role in the appeal process, lending credibility to your claim. Having your health care professional on your side can strengthen your case.
In addition to your doctor, an attorney can help you navigate the appeal process, keeping track of deadlines and ensuring you file your appeal correctly. An attorney can represent you in federal court if your case progresses to the final stage of the appeals process. Find a qualified attorney near you.
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