Medicare denials are not the end of the road. The federal government has built a structured, five-level appeal system specifically to give beneficiaries a fair shot at overturning incorrect denials. The data is clear: Medicare Advantage appeals succeed over 75% of the time. Even Original Medicare appeals have strong reversal rates at higher levels. But you need to follow the right steps, in the right order, within strict deadlines.
The Two Medicare Appeal Systems
Before diving into steps, understand there are two distinct Medicare appeal processes depending on your coverage type:
- Original Medicare (Parts A and B): Administered by Medicare Administrative Contractors (MACs). Appeals go through CMS's five-level system.
- Medicare Advantage (Part C): Administered by private insurers. Has its own five-level system but with different timelines and contacts.
Part D (prescription drugs) has yet another process — see our prescription drug appeal guide for details.
Original Medicare (Parts A & B): The 5 Levels
Level 1: Redetermination
You file a redetermination request with the same Medicare Administrative Contractor (MAC) that processed the original claim. This is the first step and is reviewed internally by the MAC.
| Detail | Information |
|---|---|
| Who reviews | Medicare Administrative Contractor (MAC) |
| Deadline | 120 days from Medicare Summary Notice (MSN) date |
| Time limit for decision | 60 days for Part B; 60 days for Part A |
| How to file | Written request to the MAC address on your MSN |
| Form | CMS-20027 or written letter |
When submitting a redetermination, include your Medicare number, the date of service, the claim number from your MSN, and any supporting documentation from your doctor explaining why the service was medically necessary.
Level 2: Reconsideration by a Qualified Independent Contractor (QIC)
If your redetermination is denied, you can escalate to a QIC — a completely independent organization from the MAC. This is often where cases genuinely improve, because the reviewer has no stake in the original decision.
| Detail | Information |
|---|---|
| Who reviews | Qualified Independent Contractor (QIC) |
| Deadline | 180 days from Level 1 denial notice |
| Decision timeline | 60 days |
| How to file | Written request to the QIC listed on your Level 1 denial |
Tip: Submit new evidence at Level 2
Level 2 is your last opportunity to submit new clinical evidence. Any evidence not submitted by the QIC review deadline generally cannot be introduced at higher levels. Make sure your physician submits a detailed letter of medical necessity before this deadline.
Level 3: Office of Medicare Hearings and Appeals (OMHA)
If the QIC denies your appeal, you can request a hearing before an Administrative Law Judge (ALJ) through the Office of Medicare Hearings and Appeals. This level requires a minimum dollar amount at stake.
- Minimum threshold: $190 (adjusted annually for inflation)
- Deadline: 60 days from Level 2 denial
- ALJ hearings can be conducted in person, by phone, or by video
- You have the right to present witnesses and evidence
- Decision expected within 90 days, though backlogs often extend this
Level 4: Medicare Appeals Council (MAC)
If the ALJ rules against you, you can request review by the Medicare Appeals Council (part of the Departmental Appeals Board at HHS). This level involves reviewing the ALJ's legal reasoning for error.
- Deadline: 60 days from ALJ decision
- No in-person hearing — decision based on written record
- Council can affirm, reverse, or remand to ALJ
- Consider legal representation at this level
Level 5: Federal District Court
If the Appeals Council decision is unfavorable, you can file suit in federal district court. This is rare and typically warrants an attorney.
- Minimum threshold: $1,870 (adjusted annually)
- Deadline: 60 days from Council decision
- This is a civil lawsuit in federal court
Medicare Advantage (Part C): How It Differs
Medicare Advantage has the same five levels but with different contact points and shorter timelines:
| Level | Reviewer | Standard Deadline | Expedited Deadline |
|---|---|---|---|
| 1 – Internal | Your MA plan | 60 days from denial | 72 hours |
| 2 – IRE | Independent Review Entity | 60 days from Level 1 | 72 hours |
| 3 – ALJ | OMHA | 60 days from Level 2 | 10 days |
| 4 – MAC | Medicare Appeals Council | 60 days from Level 3 | — |
| 5 – Court | Federal District Court | 60 days from Level 4 | — |
Expedited Appeals: When You Need a Fast Decision
If your health situation is urgent, request an expedited appeal. For Medicare Advantage, the plan must respond within 72 hours. Criteria for expedited review:
- Standard timeline would seriously jeopardize your life or health
- Waiting would jeopardize your ability to regain maximum function
- Your physician can support the urgency in writing
What to Include in Your Medicare Appeal
Regardless of the level, effective Medicare appeals include:
- Your full name, Medicare number, and date of birth
- The specific claim number and date of service being appealed
- A clear statement that you are appealing and why
- A physician's letter of medical necessity that directly addresses the denial reason
- Relevant clinical guidelines (CMS National Coverage Determinations, Local Coverage Determinations)
- Any peer-reviewed studies supporting the treatment
- Documentation of prior treatment attempts if step therapy was required
Use our free appeal letter generator to build a Medicare-specific appeal letter, or read our guide on how to write a strong appeal letter for detailed writing tips.
Sources: CMS Medicare Appeals process · Medicare.gov appeals information · CMS Medicare Advantage appeals data. Disclaimer: This article is for informational purposes only. Individual outcomes vary. Consult a benefits counselor or attorney for your specific situation. Last updated: March 2026.