Medicare Appeals Process: How Does It Work?

What is a Medicare appeal?

A Medicare appeal is a formal request to review a decision about whether Medicare or a Medicare plan will cover or pay for a health care item, service, or prescription drug.

You may appeal a decision made by Original Medicare, a Medicare Advantage plan, another Medicare health plan, or a Medicare drug plan. The exact process depends on the type of coverage involved, so the notice you receive is important.

When can you file a Medicare appeal?

You can file an appeal when you disagree with a coverage or payment decision. Common examples include a denial of payment for a service, a refusal to cover an item or drug, or a decision to stop covering certain care.

Before appealing, Medicare recommends asking your provider, supplier, or prescriber for information that may strengthen your case. This might include medical records, a statement of medical necessity, or other documentation showing why the item, service, or drug should be covered.

If you miss an appeal deadline, you may still be able to appeal if you can show good cause for filing late. Whether good cause applies depends on the facts of your situation.

What are the five levels of Medicare appeal?

Medicare appeals generally have five levels. If you disagree with the decision at one level, you can usually continue to the next level by following the instructions in the decision letter.

1. Level 1: The first appeal level. In Original Medicare, this is called a redetermination. In a Medicare Advantage plan, the starting point is usually an organization determination followed by an appeal if you disagree. In a drug plan, the starting point is usually a coverage determination followed by a redetermination.
2. Level 2: A review by an independent contractor or review entity, depending on the type of Medicare coverage.
3. Level 3: A hearing or review by the Office of Medicare Hearings and Appeals, often involving an Administrative Law Judge or attorney adjudicator. For 2026, the amount in controversy generally must be at least $200 to reach this level.
4. Level 4: Review by the Medicare Appeals Council.
5. Level 5: Judicial review in Federal district court. For 2026, the amount in controversy generally must be at least $1,960.

How does the appeals process differ by Medicare coverage type?

The appeals process varies based on the kind of Medicare coverage involved.

• Original Medicare: Start with your Medicare Summary Notice. It explains what Medicare paid or denied and how to request a redetermination.
• Medicare Advantage and other Medicare health plans: Your plan must tell you in writing how to appeal. Contact the plan and follow the instructions in the decision notice or plan materials.
• Medicare drug plans: Appeals usually begin after a coverage determination or exception request is denied. Your prescriber may be able to provide supporting information.

Because forms, addresses, and deadlines can differ, use the exact instructions in your notice rather than relying only on general rules.

How do you start a Medicare appeal?

Start by reading the notice that explains the decision you disagree with. This may be a Medicare Summary Notice, a plan denial letter, a coverage determination, or another written decision.

Your appeal request should generally identify the decision you are appealing, explain why you disagree, and include supporting documents. Keep copies of everything you send. If a form is available, using it can help ensure your request includes the information Medicare or your plan needs.

At each level, the decision letter should explain the outcome and tell you how to move to the next appeal level if you disagree.

Are fast appeals available?

Fast appeals may be available in certain time-sensitive situations, such as when covered services are being stopped or when waiting for a standard decision could seriously affect your health. The rules depend on the service and coverage type.

For some fast appeals involving the end of covered services, an independent reviewer called a Beneficiary and Family Centered Care-Quality Improvement Organization may decide whether services should continue. Your provider or plan notice should explain how to request a fast appeal and the deadline for doing so.

Can someone help you with a Medicare appeal?

Yes. You may ask a family member, friend, doctor, attorney, or other person to help, but Medicare may require written permission before that person can act for you. This is commonly done with an Appointment of Representative form.

You can also contact your State Health Insurance Assistance Program for help understanding Medicare appeal rights. If a provider or supplier is appealing on your behalf, make sure the required forms or permissions are completed and submitted with the appeal.

Official Sources