Medicare denied your claim. Before you pay the bill, know this: roughly 40โ60% of Medicare appeals succeed at the first level alone. The process is bureaucratic but winnable โ if you act before the deadlines.
This guide walks you through every step, from your first Explanation of Benefits (EOB) to the federal review board if needed.
What You'll Need Before You Start
Gather these before filing anything:
- Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) showing the denial
- Your Medicare Beneficiary Identifier (MBI) โ on your Medicare card
- The claim number from your MSN
- A letter or note from your doctor supporting the service (if available)
- Calendar reminder โ deadlines are strict and vary by appeal level
Estimated time for Level 1 appeal: 30โ60 minutes to prepare, then waiting.
Step 1 โ Read the Denial Reason Carefully
Your MSN includes a Claim Adjustment Reason Code (CARC). Common reasons:
| Code / Description | What It Means |
|---|---|
| "Not medically necessary" | Medicare's records don't support the service |
| "Benefit not covered" | Service excluded from Part A/B |
| "Duplicate claim" | Billed twice for same service |
| "Prior authorization required" | MA plan rule not met |
| "Timely filing" | Claim submitted too late by provider |
Know your reason before appealing. A "not medically necessary" denial needs your doctor's clinical notes. A "not covered" denial may need a different legal argument โ or a switch to a different service code.
Step 2 โ File a Redetermination (Level 1 Appeal)
Deadline: 120 days from the date on your MSN.
This is a request for Medicare (or your Medicare Advantage plan) to review the claim again. You have two options:
- Online: Log into MyMedicare.gov and use the Appeal a Claim tool.
- Mail: Send a written request to the address on your MSN. Include your name, MBI, claim number, and why you disagree.
Attach your doctor's supporting letter if the denial was for medical necessity. This single addition is the most common reason Level 1 appeals succeed.
Bottom line: Level 1 is your fastest path. Medicare must respond within 60 days for Part B claims. Don't skip it โ you cannot jump directly to Level 2.
Step 3 โ Request a Reconsideration (Level 2)
Deadline: 180 days from the Level 1 denial notice.
If Level 1 fails, your case goes to a Qualified Independent Contractor (QIC) โ a company separate from Medicare. They review it fresh.
Send everything you sent in Level 1, plus any new medical documentation. The QIC has 60 days to decide. Response arrives by mail.
At this stage, consider involving your doctor directly. A peer-to-peer review call between your physician and the QIC reviewer can change outcomes, especially for medical necessity disputes.
Step 4 โ Request an ALJ Hearing (Level 3)
Deadline: 60 days from the Level 2 denial.
Minimum amount in controversy: $180 (2026 threshold).
An Administrative Law Judge (ALJ) hears your case โ this can be done in-person, by video, or by phone. You may bring witnesses, including your doctor.
Prepare a written statement explaining:
- Why the service was medically necessary
- The specific Medicare coverage rule that applies
- Any clinical guidelines supporting the decision
ALJ hearings have historically favored appellants more than lower levels. Wait time can be 18โ24 months due to backlog โ patience required.
Step 5 โ Appeals Council and Federal Court
If the ALJ rules against you, two more levels remain:
- Level 4 โ Medicare Appeals Council: Review the ALJ decision. Submit within 60 days of ALJ ruling.
- Level 5 โ Federal District Court: Only if amount in controversy exceeds $1,880 (2026). File within 60 days of Council decision.
Most disputes resolve before reaching federal court. Only a small fraction of high-dollar cases escalate this far.
Common Mistakes That Sink Appeals
- Missing the deadline. The 120-day Level 1 window closes hard. Set a reminder the day you get your MSN.
- Not including a doctor's letter. "Not medically necessary" denials almost always require clinical documentation.
- Accepting the first denial. Most people stop here. The data says keep going.
- Appealing the wrong entity. Medicare Advantage appeals go to your plan first, not CMS directly.
Start a Medicare Appeal on Medicare.govOfficial appeals portal โ track status online โ
What If You Have Medicare Advantage?
Medicare Advantage (Part C) appeals follow a different track than Original Medicare. Your plan must first review the denial internally. Key differences:
- Level 1: Internal appeal to your MA plan (72 hours for urgent care, 30 days for standard)
- Level 2: IRE (Independent Review Entity) โ not a QIC like in Original Medicare
- Emergency care: MA plans cannot deny emergency claims if a "prudent layperson" would consider it an emergency
If your MA plan denies an urgent request, you can request an expedited appeal โ the plan must respond within 72 hours.
One More Resource: Your State SHIP
Every state has a State Health Insurance Assistance Program (SHIP) โ free, unbiased counselors who help with exactly this. They can review your denial letter, help you write your appeal, and coach you through the hearing process at no cost.
Find your state's SHIP at shiphelp.org. This is the single most underused Medicare resource for people navigating denials.
Their counselors know the specific quirks of your state's local carriers and can sometimes flag procedural errors in the denial that you'd never catch yourself. Bring your MSN, your doctor's notes, and your MBI to the first call.
