Medicare Claim Denied: How to Appeal Medicare Decisions (All 5 Levels)

Medicare Claim Denied: What Happens Next

Receiving a Medicare claim denial can feel overwhelming, especially when you are dealing with health challenges at the same time. But a denial is not the end. Medicare has one of the most comprehensive multi-level appeals processes in the entire US healthcare system, and a substantial percentage of appealed Medicare decisions are ultimately overturned.

This guide explains every level of the Medicare appeals process — from the initial redetermination all the way to federal court — with specific timelines, strategies, and tips for each stage. Whether your denial involves Medicare Part A, Part B, Part C (Medicare Advantage), or Part D (prescription drug coverage), the path forward is mapped out here.

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Why Medicare Claims Get Denied

Understanding the basis of your denial is essential before you appeal. The most common reasons Medicare denies claims include:

Medically unnecessary services. Medicare covers services that are "medically necessary" — meaning reasonable and necessary for diagnosis or treatment. If Medicare or your health plan determines a service was not medically necessary, it will deny payment. This is the most common denial reason.

Coverage exclusions. Medicare does not cover everything. Routine dental care, most vision care, hearing aids, and long-term custodial care are among the notable exclusions. Denials based on exclusions require you to argue either that the exclusion does not apply or that the service falls within an exception.

Prior authorization not obtained. For Medicare Advantage (Part C) plans, prior authorization is often required for specialist visits, procedures, and durable medical equipment. Failure to obtain it results in denial.

Billing errors. The service was provided and should be covered, but the claim was submitted with an incorrect code, duplicate code, or missing information. These administrative denials can often be resolved quickly by the provider resubmitting a corrected claim.

Coordination of benefits issues. If Medicare is not the primary payer (for example, if you have employer coverage that pays first), coordination of benefits errors can result in denial.

Non-covered providers. Services from providers who do not accept Medicare assignment may result in claim denials or higher cost-sharing.

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The Five Levels of Medicare Appeals

Level 1: Redetermination

Who reviews it: The Medicare Administrative Contractor (MAC) — the company that processes Medicare Part A and Part B claims in your region. For Part C or D, your plan reviews its own denial first.

Deadline to file: Within 120 days of receiving your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB).

How to file:

• Write a letter requesting redetermination and send it to the address on your MSN or claim denial notice. Include your Medicare number, the claim number, the specific service or item denied, and a brief explanation of why you believe the denial is incorrect.
• Attach supporting documentation: your doctor's letter of medical necessity, clinical notes, peer-reviewed medical literature if relevant.
• You can also call 1-800-MEDICARE (1-800-633-4227) for guidance.

Timeline: The MAC must respond within 60 days for standard redetermination requests. For expedited requests (involving urgent care), the deadline is 72 hours.

Outcome: A large proportion of denials overturned at this level — particularly billing errors and cases where additional documentation clarifies medical necessity.

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Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

Who reviews it: A Qualified Independent Contractor (QIC) — an independent organization contracted by CMS to provide a second, unbiased review. For Part C and D, this is an Independent Review Entity (IRE) such as MAXIMUS Federal Services.

Deadline to file: Within 180 days of receiving the redetermination decision.

How to file:

• Write a formal reconsideration request to the QIC (the address will be on your redetermination decision letter).
• Include all previous documentation plus any new evidence — especially additional medical records, specialist opinions, or peer-reviewed literature supporting medical necessity.
• This is the level where submitting a strong package of medical evidence is most critical.

Timeline: 60 days for standard requests. 72 hours for expedited requests.

Cost: Free for all Medicare beneficiaries.

Tip: The QIC review is truly independent and can overturn both the MAC and the original denial. Spend time building the strongest possible medical evidence package for this level.

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Level 3: Administrative Law Judge (ALJ) Hearing

Who reviews it: An Administrative Law Judge employed by the Office of Medicare Hearings and Appeals (OMHA), part of the US Department of Health and Human Services (HHS).

Deadline to file: Within 60 days of receiving the QIC's decision.

Amount in controversy: For 2025, the minimum amount in dispute must be at least $180 (this amount is adjusted annually).

How to file:

• File a request for ALJ hearing using CMS Form 20033 or a written request to OMHA.
• You may request an in-person hearing, a telephone hearing, or a video teleconference hearing.
• You may be represented by an attorney, a non-attorney representative, or represent yourself.

Timeline: OMHA aims to resolve ALJ hearings within 90 days of receiving the hearing request, but processing times have historically been longer due to caseload.

Why this level matters: ALJ hearings are formal legal proceedings. The ALJ will review all evidence de novo — meaning a fresh review of everything. Representation by a Medicare-experienced attorney or advocate can significantly improve outcomes at this level.

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Level 4: Medicare Appeals Council

Who reviews it: The Medicare Appeals Council, part of the HHS Departmental Appeals Board (DAB).

Deadline to file: Within 60 days of receiving the ALJ decision.

How to file:

• Submit a written request for review to the Medicare Appeals Council at: Departmental Appeals Board, Medicare Appeals Council, 330 Independence Avenue SW, Washington DC 20201.
• The request must identify the ALJ decision and explain why you believe it was wrong.

Timeline: No statutory deadline, but the Council aims to decide cases within 90 days. In practice, cases can take longer.

Scope of review: The Council can review the ALJ's decision for legal errors, not just factual errors. You can argue that the ALJ misapplied the Medicare coverage rules.

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Level 5: Federal District Court

Who reviews it: A US Federal District Court.

Deadline to file: Within 60 days of receiving the Medicare Appeals Council's decision.

Amount in controversy: The minimum amount in dispute must be at least $1,870 (for 2025, adjusted annually).

How to file:

• File a civil complaint in the Federal District Court for your jurisdiction.
• Legal representation by an attorney is strongly recommended at this level.

Scope of review: The court reviews the administrative record to determine whether the Medicare Appeals Council's decision was arbitrary, capricious, not supported by substantial evidence, or contrary to law.

This level is rare in most ordinary Medicare disputes but becomes relevant in large or complex cases — for example, hospital claims for extended inpatient stays or expensive durable medical equipment.

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IRMAA Appeals: A Special Case

If you pay the Income-Related Monthly Adjustment Amount (IRMAA) surcharge on your Medicare Part B or Part D premiums, and you believe it is incorrect, you can appeal to the Social Security Administration (SSA). Common grounds for IRMAA appeals:

• Your income has decreased significantly since the reference tax year (for example, due to retirement, divorce, or loss of a spouse).
• The IRS provided incorrect income information to the SSA.

File a Life-Changing Event request using SSA Form SSA-44 available at ssa.gov. This is separate from the standard Medicare claims appeal process.

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Tips for Winning Your Medicare Appeal

Get your doctor involved. A letter of medical necessity from your treating physician is the single most persuasive piece of evidence in a Medicare appeal. The letter should explain why the denied service was clinically appropriate and necessary for your specific condition, not just "helpful."

Cite the Local Coverage Determination (LCD) or National Coverage Determination (NCD). Medicare publishes detailed coverage policies called LCDs and NCDs that specify exactly what conditions and circumstances qualify for coverage. Find the relevant LCD/NCD at cms.gov/medicare-coverage-database and show specifically how your case meets the coverage criteria.

Use the Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs). For hospital discharge disputes (when you believe you are being discharged too soon), contact your BFCC-QIO — Kepro or other regional QIOs — for a free, immediate review. This must be requested before you leave the hospital.

Keep copies of everything. Every denial, every appeal, every response, and every document submitted.

Don't give up at Level 1 or 2. Statistics consistently show that a significant proportion of Medicare appeals are won at Levels 2 and 3. The QIC and ALJ provide genuinely independent reviews.

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Using ClaimBack to Draft Your Appeal Documents

Crafting an effective Medicare appeal letter — one that correctly identifies the applicable LCD/NCD, addresses the specific denial reason, and presents medical evidence persuasively — requires time and knowledge. ClaimBack at claimback.app helps you generate a professional, well-structured appeal letter tailored to Medicare Part A, Part B, Part C, or Part D denials. Getting the language right at Levels 1 and 2 can resolve your dispute without needing to proceed to an ALJ hearing.

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Conclusion

A denied Medicare claim is a challenge, not a dead end. The five-level Medicare appeals process provides multiple chances to reverse an incorrect denial, and thousands of beneficiaries successfully overturn Medicare decisions every year. Start with the redetermination at Level 1, build your medical evidence at Level 2, and escalate to an ALJ hearing if needed. Use every free resource available — including ClaimBack at claimback.app for drafting your appeal letters — and do not accept an unjust denial of the coverage you have earned.