How do I appeal a Medicare denial?

Start with the notice in front of you. For Original Medicare, use the Medicare Summary Notice (MSN) deadline and file a redetermination with the Medicare Administrative Contractor (MAC) listed on the MSN — often by circling the denied line, writing why you disagree, and mailing it, or by using CMS Form CMS-20027. For Medicare Advantage, follow the plan's organization-determination notice and file a Level 1 reconsideration with the plan. For Part D, start with a coverage determination (or exception) and, if denied, a plan redetermination. Do not use commercial ERISA 180-day clocks on a Medicare case.

How long do I have to appeal Original Medicare versus Medicare Advantage or Part D?

Original Medicare generally gives you 120 days from receipt of the initial determination on the Medicare Summary Notice to request a redetermination; the MSN prints the deadline to use. Medicare.gov currently instructs Medicare Advantage and Part D enrollees to file a Level 1 appeal within 65 days from the date on the plan's initial denial notice. Later levels have their own clocks (for example, 180 days to a Qualified Independent Contractor after an Original Medicare redetermination). Always follow the date on your notice.

What is the difference between a Medicare redetermination and a reconsideration?

In Original Medicare, a redetermination is Level 1: a new review by MAC staff who were not involved in the initial claim decision. A reconsideration is Level 2: an independent review by a Qualified Independent Contractor (QIC). In Medicare Advantage, Level 1 is a plan reconsideration of an organization determination. In Part D, Level 1 is a plan redetermination of a coverage determination, and Level 2 is a reconsideration by a Part D Independent Review Entity (IRE). The same English words are used in different tracks — read the notice for your track.

Can I get an expedited Medicare appeal if waiting would harm my health?

Yes, when the standard clock could seriously jeopardize your life, health, or ability to regain maximum function. Medicare Advantage plans must decide an expedited (fast) appeal within 72 hours if the plan or your doctor says waiting for the standard timeframe would put your health at serious risk. Part D plans have a parallel fast process for coverage you have not already received and paid for. Hospital, skilled nursing facility, home health, CORF, and hospice service-ending notices use a separate fast-appeal process — that is not the same as appealing a claim denial on an MSN.

Does a Medicare Advantage denial automatically go to independent review?

If your Medicare Advantage plan fully or partly upholds its denial at Level 1, Medicare.gov states the plan automatically forwards the case to an Independent Review Entity (IRE) for Level 2. Part D is different: if the plan upholds the denial, you generally must request the Part D IRE reconsideration yourself within 60 days of the plan's decision. Original Medicare also requires you to request the QIC reconsideration; it is not automatic.

Is Medicaid the same as a Medicare appeal?

No. Medicaid uses state eligibility and coverage rules and state fair-hearing processes. Medicare uses federal Medicare appeals (Original Medicare under 42 CFR Part 405 Subpart I; Medicare Advantage organization determinations; Part D coverage determinations). If you have both Medicare and Medicaid (dual eligibility), a denial may need a Medicare appeal, a Medicaid appeal, or both — depending on which program denied the item. Do not mail a Medicaid fair-hearing request to a Medicare Administrative Contractor and expect it to count.

What documents should I attach to a Medicare appeal?

Attach a copy of the MSN or plan denial notice, your Medicare Number, the dates of service or the drug name, and a short written reason you disagree. Clinical records from the treating provider — progress notes, test results, and a statement that the item or drug is needed — make the file easier to review. If someone else is filing for you, include a valid appointment of representative (CMS-1696 or a writing that meets 42 CFR 405.910). Extra Help (the Part D low-income subsidy) is a separate appeal if the issue is Extra Help eligibility, not a coverage denial.

Can AppealFlow file my Medicare appeal for me?

No. AppealFlow can draft a letter you can edit. You still have to file on the Medicare form, MAC address, plan portal, or phone process printed on your notice. Medicare.gov and CMS publish the official steps and forms. A drafted letter is not a filed redetermination, reconsideration, or coverage determination.

How to Appeal a Medicare Denial

By AppealFlow editorial•16 min read•Published August 2026

You can appeal a Medicare coverage or payment denial, but the clock and forms depend on which Medicare you have. Original Medicare generally starts with a redetermination to the Medicare Administrative Contractor using the deadline printed on your Medicare Summary Notice (often 120 days). Medicare Advantage and Part D use plan-specific notices; Medicare.gov currently instructs enrollees to file a Level 1 appeal within 65 days from the date on the initial denial notice. Do not apply commercial ERISA 180-day rules to a Medicare case.

Which Medicare You Have Changes the Appeal

Key Takeaway: Original Medicare (Parts A and B), Medicare Advantage (Part C), and Part D drug plans use different notices, contractors, and clocks. Read the denial in your hand. A commercial ERISA 180-day appeal window does not control a Medicare case.

Medicare.gov's claims and appeals hub states that you can file an appeal if you disagree with a coverage or payment decision by Original Medicare, a Medicare health plan, or a Medicare drug plan. The same page treats claims, appeals, and quality complaints (grievances) as separate tools. An appeal challenges coverage or payment. A grievance challenges customer service or quality of care.

Medicare.gov's filing page lists five general appeal levels and sends you to a different track for Original Medicare, Medicare health plans, and drug plans. Confirm which card paid — or refused — the service before you pick a form.

Original Medicare: Medicare Summary Notice (MSN) from a Medicare Administrative Contractor (MAC).
Medicare Advantage: organization determination from the plan (written or, in some cases, oral).
Part D: coverage determination or exception decision from the drug plan.

Medicaid is a different system. State Medicaid agencies and Medicaid managed-care plans use state notices and fair hearings. Dual eligibility (Medicare and Medicaid) can mean two denials and two processes. Do not mail a Medicaid hearing request to a MAC and expect it to count as a Medicare appeal.

Original Medicare: MSN to Redetermination, QIC, ALJ, Council, and Court

Key Takeaway: Original Medicare Part A and Part B claim appeals follow 42 CFR Part 405 Subpart I and Section 1869 of the Social Security Act. Level 1 is a redetermination by the MAC. Use the deadline printed on the MSN — CMS describes that first-level filing window as 120 days from receipt of the initial determination.

CMS's Original Medicare (fee-for-service) appeals page lists five levels: MAC redetermination; Qualified Independent Contractor (QIC) reconsideration; Office of Medicare Hearings and Appeals (OMHA) decision; Medicare Appeals Council review; and judicial review in federal district court.

Medicare.gov's Original Medicare appeals page tells you to start with the MSN, file by the date on that notice, and either complete a redetermination request form or follow the MSN instructions (circle the line, explain why you disagree, include your Medicare Number, and mail it to the MAC address on the last page). CMS Form CMS-20027 is the Medicare redetermination request form.

Level	Who reviews	Typical filing clock (confirm on the notice)
1 — Redetermination	MAC staff not involved in the initial claim decision	Deadline on the MSN; CMS describes 120 days from receipt of the initial determination (receipt presumed 5 days after the notice date unless there is evidence otherwise)
2 — Reconsideration	Qualified Independent Contractor (QIC)	Medicare.gov: 180 days after you get the MAC decision letter or an MSN showing the redetermination
3 — OMHA	Administrative Law Judge or attorney adjudicator	60 days from the QIC decision; 2026 ALJ amount-in-controversy is $200 (Medicare.gov)
4 — Appeals Council	Medicare Appeals Council	60 days after you get the OMHA decision
5 — Federal court	U.S. district court	60 days after the Council decision; 2026 federal-court amount-in-controversy is $1,960 (claims may be combined; confirm on Medicare.gov)

CMS generally issues a redetermination decision within 60 days of receiving the request. If someone else files for you, use an appointment of representative (CMS-1696 or a writing that meets 42 CFR 405.910). Free counseling is available from a State Health Insurance Assistance Program (SHIP).

How Do Medicare Advantage Organization Determinations Work?

Key Takeaway: Coverage decisions in a Medicare Advantage plan are called organization determinations. Level 1 is a plan reconsideration. Medicare.gov currently says you, your representative, or your doctor must file that appeal within 65 days from the date on the plan's initial denial notice. If the plan upholds the denial, it automatically forwards the case to an Independent Review Entity.

Follow Medicare.gov's Medicare health plan appeals page and the instructions on your denial. Contact the plan using the number on your membership card. If an in-network provider refers you for a covered service without getting an advance organization determination, Medicare.gov calls that “plan directed care” and says you usually owe no more than plan cost sharing — confirm with the plan.

How long the plan has to decide a Level 1 appeal depends on the type of request. Medicare.gov lists standard timeframes of 30 days for a pre-service appeal, 60 days for a payment appeal, and 7 days for a Part B drug appeal, with a 72-hour fast appeal when waiting for the standard clock may seriously jeopardize your life, health, or ability to regain maximum function. Some timeframes may be extended by up to 14 days when the plan says the extension is in your interest.

After an Independent Review Entity (IRE) decision, Medicare.gov gives 60 days to request an OMHA hearing. For 2026, the OMHA amount-in-controversy minimum on that page is $200, and the federal-court minimum is $1,960. Special Needs Plans still owe written appeal instructions; PACE and some Cost plans follow different rules described on the same Medicare.gov page.

How Do Part D Coverage Determinations Work?

Key Takeaway: Part D appeals start with a coverage determination (including an exception request). Level 1 is a plan redetermination. Medicare.gov currently uses a 65-day filing window from the date on the initial denial notice. Unlike Medicare Advantage, a Part D plan that upholds a denial does not automatically send the case to independent review — you generally must request the Part D IRE within 60 days.

Medicare.gov's drug-plan appeals page explains that you have a right to a coverage determination, orally or in writing, to see whether a drug is covered. For a drug you have not received yet, you or your prescriber can call, write, or use the model coverage determination request. For reimbursement of a drug you already bought, the request must be in writing. An exception requires a prescriber statement explaining the medical reason.

Standard Part D appeal decision clocks on Medicare.gov are 7 days for a benefits (coverage) appeal and 14 days for a payment appeal, with a 72-hour fast appeal when waiting for the standard 7-day decision may seriously jeopardize your health. You cannot get a fast decision solely to get paid back for a drug you already obtained.

Extra Help (the Part D low-income subsidy) is a separate eligibility appeal if the issue is Extra Help itself, not whether the plan covers a drug. See Extra Help appeals for the Part D low-income subsidy.

When Can I Ask for an Expedited Medicare Appeal?

Key Takeaway: Ask for a fast decision when waiting for the standard timeframe may seriously jeopardize your life, health, or ability to regain maximum function. That standard is on Medicare.gov for Advantage and Part D. Ending hospital, SNF, home health, CORF, or hospice services uses a separate fast-appeal notice — not the MSN redetermination form.

For Medicare Advantage items and services, Medicare.gov says the plan must give its fast-appeal decision within 72 hours if the plan determines — or your doctor tells the plan — that waiting for the standard clock puts your health at serious risk. Part D uses the same 72-hour fast-appeal decision when the issue is getting the drug, not repayment.

Medicare.gov also describes a different “fast appeal” when you think Medicare-covered services are ending too soon in a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice. The provider must give a written notice before services end. That process is not a substitute for appealing a claim line on an MSN. For rehab discharge steps, see how to appeal a Medicare discharge from a rehab facility.

Weak vs. Strong Medicare Appeal Language

Key Takeaway: Name the track (Original Medicare, Advantage, or Part D), the notice date, the item or drug, and the clinical reason coverage should apply. Vague complaints about “Medicare being unfair” do not tell the reviewer which regulation or plan rule to apply.

❌ Weak Request	✓ Strong Request
“Please approve this. I have 180 days like my old job insurance.”	“This is an Original Medicare Part B claim on MSN dated [date], claim [number]. I request a redetermination under 42 CFR Part 405 Subpart I by the deadline printed on the MSN. ERISA 29 CFR 2560.503-1 does not apply.”
“My Advantage plan denied it. Send this to Medicare in Baltimore.”	“I request a Level 1 reconsideration of the organization determination dated [date] for [item] on dates of service [dates]. Filing within 65 days of that notice date as instructed on Medicare.gov. Attached: denial, clinical notes, and appointment of representative if applicable.”
“The pharmacy said the drug is not covered. I already paid cash.”	“I request a written Part D coverage determination / exception for [drug, strength, NDC if known]. Prescriber supporting statement is attached. If this is a reimbursement request, it is submitted in writing as Medicare.gov requires for drugs already purchased.”

Need a Draft Letter Before You File?

AppealFlow can draft a letter that names the denial and the clinical facts you enter. It is a draft — you still file on the Medicare form, MAC address, or plan portal printed on your notice.

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What to File, and What Not to Mix With This Appeal

Key Takeaway: File the packet the notice names. Attach the notice, identifiers, dates, and clinical support. Do not substitute a commercial insurance appeal letter, a Medicaid fair-hearing form, or a hospital-discharge fast appeal for an MSN redetermination.

Copy of the MSN or plan denial, including the date and any appeal number
Your name, address, and Medicare Number as they appear on your card
Items, services, or drug, with dates of service
A written reason you disagree, plus treating-provider notes or a supporting statement
Appointment of representative if someone else is filing

If you miss a deadline, Medicare may still accept a late filing for good cause — CMS describes that process on its good-cause late filing page. Explain the delay in writing and attach evidence. That is not a reason to wait.

Frequently Asked Questions

Common questions about Original Medicare redeterminations, Medicare Advantage organization determinations, Part D coverage determinations, and expedited appeals.

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AppealFlow.net drafts a letter from the facts you enter. For Medicare, you still submit CMS-20027, the MSN instructions, or your plan's organization-determination or coverage-determination process. The draft is not a filed appeal.

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Disclaimer: This article is for educational purposes only and does not constitute medical, legal, or financial advice. AppealFlow.net is not a healthcare provider, insurance broker, or law firm. Medicare appeal clocks, forms, and amount-in-controversy thresholds change — verify current requirements with the notice you received, Medicare.gov, your plan, or 1-800-MEDICARE before taking action. For medical emergencies, call 911. See our full disclaimer.