How to Appeal a Medicare Denial: Levels, Deadlines, Free Help

Last reviewed: July 2026

A denial is not the final word

Every year, Medicare and private Medicare plans deny millions of claims and prior-authorization requests — and most people never push back. KFF's analysis of 2024 Medicare Advantage data found that only 11.5% of denied prior-authorization requests were appealed, yet 80.7% of the appeals that were filed got the denial partially or fully overturned. Those numbers do not guarantee anything about your case, but they make one point clearly: appeals are a normal, built-in part of Medicare, and they often work.

The appeal path you follow depends on how you get your Medicare — Original Medicare or a Medicare Advantage plan — and whether the denial involves a Part D prescription drug. Whatever the path, the two things that sink most appeals are missed deadlines and missing paperwork, so start by reading the denial notice carefully: it tells you why coverage was denied, how to appeal, and by when.

The five appeal levels in Original Medicare

In Original Medicare, denials show up on your Medicare Summary Notice (MSN), the statement mailed every three months (also viewable in your Medicare.gov account). If you disagree with a decision, there are five levels of appeal:

Level 1 — Redetermination. A fresh review by the Medicare Administrative Contractor that processed the claim, done by staff who were not involved in the original decision. File within 120 days of receiving the MSN, using the Redetermination Request form or a written request. You generally get a decision within 60 days.
Level 2 — Reconsideration. If you disagree with the redetermination, a Qualified Independent Contractor (QIC) reviews the case. File within 180 days of the redetermination decision; the QIC generally decides within 60 days.
Level 3 — Hearing with the Office of Medicare Hearings and Appeals (OMHA). File within 60 days of the QIC decision. For appeals filed in 2026, the amount in dispute must be at least $200. An administrative law judge (or, if you agree, an attorney adjudicator) reviews the case; hearings are usually by phone or video.
Level 4 — Medicare Appeals Council. File within 60 days of the OMHA decision.
Level 5 — Federal district court. File within 60 days of the Council's decision. For 2026, the amount in dispute must be at least $1,960.

Most cases are resolved at the first two levels. At every level, you can (and should) add supporting evidence — a letter from your doctor explaining why the care was medically necessary is often the single most useful document.

Appeals in Medicare Advantage plans

In Medicare Advantage, the first round happens inside your plan, but the later levels rejoin the same federal ladder. If your plan denies a service, item, or payment, you have 65 days from the date on the denial notice to ask the plan for a reconsideration. For a service you have not yet received, the plan generally must answer a standard appeal within 30 days (payment appeals can take up to 60 days). If waiting could seriously harm your health, you can request an expedited appeal, which the plan must decide within 72 hours.

Medicare Advantage has an important safeguard: if the plan upholds its own denial, it must automatically forward your case to an Independent Review Entity (IRE) — an outside reviewer under contract with Medicare — for a level 2 appeal. You do not have to request this step. If the IRE also rules against you, you can continue to OMHA (the $200 minimum applies), the Medicare Appeals Council, and federal court, on the same 60-day clocks described above.

Also new for 2026: under a federal rule that took effect January 1, 2026, Medicare Advantage plans must decide standard prior-authorization requests within 7 calendar days and expedited requests within 72 hours, and must give a specific reason when they deny one — which makes the denial easier to rebut on appeal.

Part D drug denials work a little differently

If your drug plan won't cover a prescription at the pharmacy counter, the first formal step is asking the plan for a coverage determination — including an "exception" if the drug isn't on the formulary or sits on an expensive tier. Your prescriber's supporting statement is key here. The plan must answer within 72 hours for a standard request or 24 hours for an expedited one.

If the answer is no, you have 65 days from the date on the denial notice to request a redetermination (level 1 appeal). The plan must decide within 7 days for a standard appeal or 72 hours for an expedited one. From there, the path mirrors Medicare Advantage: an IRE reconsideration at level 2 (though for drugs you must request it yourself), then OMHA, the Council, and federal court, subject to the same dollar minimums and 60-day deadlines.

Fast-track appeals when your care is ending

Separate, much faster appeal rights apply when Medicare coverage of ongoing care is about to stop — and they work in both Original Medicare and Medicare Advantage:

Hospital discharge. Within two days of admission you should receive "An Important Message from Medicare" explaining your rights. If you think you're being discharged too soon, call the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) listed on the notice no later than midnight on your planned discharge day. The QIO reviews quickly, and if you met the deadline you generally aren't billed for the extra hospital days during the review (aside from normal cost-sharing) through noon of the day after the QIO decides.
Skilled nursing, home health, hospice, or outpatient rehab. You must get a Notice of Medicare Non-Coverage at least two days before covered services end. To appeal, contact the QIO by noon of the day before coverage is scheduled to stop.

These deadlines are unforgiving, so act the same day you get the notice — even a one-day delay changes your financial protections. For what Medicare covers and doesn't in these settings, see our guide to what Medicare doesn't cover.

How to give your appeal its best chance

Keep every notice, and note the date you received it — deadlines run from the notice or receipt date.
Ask your doctor for a letter explaining why the item or service is medically necessary, and attach relevant medical records.
Put your appeal in writing, keep copies, and send it in a way you can track.
If your health can't wait, say so explicitly and request an expedited appeal.
You can appoint a representative — a family member, friend, advocate, or attorney — to handle the appeal for you.
Missed a deadline? You can still file and explain your "good cause" for being late; the reviewer decides whether to accept it.

Whether an appeal makes sense — and how far to take it — depends on your medical situation, the dollars at stake (see Medicare costs for 2026), and the reason for the denial. That's a personal decision best made with official help, not a blog post.

Where to get free help

You do not have to do this alone, and the best help is free:

Your State Health Insurance Assistance Program (SHIP) offers free, unbiased one-on-one counseling on denials and appeals. Find your state program at shiphelp.org or call 1-877-839-2675.
1-800-MEDICARE (1-800-633-4227) can explain a denial, confirm deadlines, and help you check appeal status; medicare.gov has the forms.
The Medicare Rights Center, an independent nonprofit, runs a national consumer helpline at 800-333-4114.
If cost is part of the problem, our guide to help paying for Medicare covers programs that lower premiums and cost-sharing.

Sources

This guide is for general education only and is not medical, legal, insurance, or financial advice. For decisions about your own coverage, use official sources or free help from your SHIP counselor.