How to Appeal a Medicare Coverage Decision: A Step-by-Step Guide 

If your Medicare plan denies coverage for a medical service or item, it can be confusing, frustrating and sometimes scary. But the good news is that you have the right to appeal.  

At The Best Senior Services, we’re here to guide you through the process of filing a Medicare appeal step by step, so you don’t have to navigate it alone. 

What Is a Medicare Appeal? 

A Medicare appeal is the formal process of challenging a decision made by Medicare or a Medicare Advantage plan when it denies payment for a service, item, or prescription drug that you believe should be covered. Whether you’re enrolled in Original Medicare or Medicare Advantage, you can file a Medicare appeal if you disagree with a coverage or payment decision. 

Why Was My Claim Denied? 

Before you begin the appeal process, it’s important to understand why your claim was denied. You’ll typically find this information on your: 

• Medicare Summary Notice (MSN) for Original Medicare 

• Explanation of Benefits (EOB) for Medicare Advantage or Part D plans 

Common reasons for denial include: 

• The service isn’t considered medically necessary 

• The provider isn’t in your plan’s network 

• Incorrect billing codes 

• Lack of documentation 

How to File a Medicare Appeal: Step-by-Step 

Step 1: Review Your MSN or EOB 

Carefully read your MSN or EOB to find the reason for the denial. This document also includes instructions on how and where to start your appeal. 

Step 2: Submit a Redetermination Request Form 

The first level of appeal under Original Medicare is called redetermination. To start, complete the Redetermination Request Form (CMS-20027) and submit it to your Medicare Administrative Contractor (MAC) at the address listed on your MSN. 

Tips: 

• Include supporting documentation from your healthcare provider 

• Be sure to appeal within 120 days of receiving your MSN 

Step 3: Request a Reconsideration (If Denied Again) 

If the MAC denies your redetermination, the second level is a reconsideration by a Qualified Independent Contractor. At this stage, you may want to write a Medicare reconsideration letter explaining why you disagree with the denial and include medical records or expert opinions to strengthen your case. 

Step 4: Request a Hearing with an Administrative Law Judge (ALJ) 

Still, denied? The next step is a hearing before an Administrative Law Judge (ALJ). This can be done by phone or video conference, and it allows you to present your case in greater detail. 

Important: Your appeal must involve at least $180 (2025 threshold) to qualify for this level. 

Step 5: Escalate to the Medicare Appeals Council or Federal Court 

If the ALJ does not rule in your favor, you can escalate your appeal to the Medicare Appeals Council, and finally, the Federal District Court as the last step. 

Original Medicare vs. Medicare Advantage: What’s Different? 

The appeals process differs slightly between Original Medicare and Medicare Advantage (Part C) or Part D drug plans. With Advantage or Part D, you appeal directly through your plan provider, not Medicare.gov. However, you still have the same appeal rights and levels of review. 

Tips for a Successful Medicare Appeal 

• Act quickly: Pay attention to deadlines typically 60 or 120 days after your MSN/EOB. 

• Keep everything: Maintain copies of forms, letters, medical records, and correspondence. 

• Get help: Your doctor or provider can write letters to support your case. 

• Use Medicare.gov: Visit Medicare.gov’s appeals page for official forms and instructions. 

FAQs 

What is a Medicare appeal? 

A Medicare appeal is a formal request to review and reverse a decision where Medicare or a Medicare Advantage plan denies coverage or payment. You have the right to appeal if you believe the service or item should be covered. 

How do I know if I can file a Medicare appeal? 

You can file an appeal if you receive a denial in your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB). These documents explain what was denied and how to start your appeal. 

What is a Redetermination Request Form? 

The Redetermination Request Form (CMS-20027) is the official form used for the first level of appeal under Original Medicare. It must be submitted to your Medicare Administrative Contractor (MAC) within 120 days of your MSN. 

What’s the deadline for filing a Medicare appeal? 

For most Medicare appeals, you must file within 120 days of the date listed on your MSN or denial notice. Always check your specific notice, as some deadlines may vary based on the type of plan. 

Can I appeal a denial from a Medicare Advantage plan? 

Yes. If you’re in a Medicare Advantage (Part C) plan, you appeal directly through your insurance provider. The process may differ slightly from Original Medicare, but you still have the same rights to escalate the appeal if needed. 

What happens after I file a Medicare appeal? 

After you file your appeal, Medicare or your plan will review the request and send a decision by mail. If denied again, you can move to the next level of the appeals process. 

Do I need a lawyer to appeal a Medicare decision? 

No, a lawyer is not required. However, you can get help from your doctor, a caregiver, or a trusted service which can assist with documentation and filing. 

How long does the Medicare appeal process take? 

Timeframes vary depending on the appeal level. A first-level decision usually takes about 60 days from the date your form is received, but higher levels like ALJ hearings may take longer. 

What should I include with my Medicare appeal? 

Include your denial notice, the Redetermination Request Form, and any supporting documents such as medical records, provider letters, or a personal statement explaining your case. 

Can The Best Senior Services help me file a Medicare appeal? 

Absolutely! We provide one-on-one support to help you understand denial reasons, fill out forms correctly, and strengthen your appeal. Our team is here to guide you through every step of the process.