Medicare Appeals: How to Challenge a Denied Claim

Most people don’t even know they can fight back.

That’s the thing I’ve seen over and over in 20 years of sitting across from Medicare beneficiaries at kitchen tables, in community center folding chairs, in church basements. Someone gets a denial letter, they read it once, feel a knot in their stomach, and quietly accept it. They figure Medicare must know best. Or they worry that appealing will somehow cause more trouble. Or they just don’t know where to start.

Here’s what I tell people in that moment: the appeals process is your right. It’s written into the law. And in my experience, a well-prepared appeal wins more often than most people expect.

Why Denials Happen (And Why They’re Not Always Final)

Medicare denials land for all kinds of reasons. Sometimes it’s a billing code that doesn’t match the diagnosis. Sometimes a service gets flagged as “not medically necessary” based on automated review. I once helped a woman named Carol, from a small town outside Pittsburgh, who’d been denied a CPAP (Continuous Positive Airway Pressure) machine even though her sleep study showed severe apnea. The denial letter cited “insufficient documentation.” Her doctor’s notes were right there in the file. We requested a Redetermination, her doctor wrote two paragraphs clarifying the medical necessity, and the denial was reversed within 60 days. No lawyer, no complicated forms. Just persistence and the right paperwork.

The Centers for Medicare & Medicaid Services reports that denial reversal rates vary significantly by type, but the consistent finding across years of data is that beneficiaries who appeal often win, and beneficiaries who don’t appeal almost never do. That math alone should change how you look at a denial letter.

The Five Levels, Explained Simply

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The Medicare appeals process has five formal levels, and they escalate in both formality and decision-making authority. As of August 2026, these apply to Original Medicare (Parts A and B), Medicare Advantage (Part C), and Medicare Part D (prescription drug coverage), though the specific steps differ slightly for Part D and Advantage plans.

Here’s a breakdown of all five:

One thing most guides don’t mention: to reach Level 3, the amount in dispute has to meet a minimum threshold. Currently that figure is adjusted each year, so check Medicare.gov for the updated number before assuming you qualify for an ALJ hearing.

Most people resolve things at Level 1 or 2. Level 5 federal court is rare. I’ve only seen it twice in my career, both involving long, complicated inpatient stay disputes.

How to Actually File a Level 1 Appeal

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This is where people often freeze, so let me walk through it concretely.

You’ll file what’s called a Redetermination Request. For Original Medicare, you send it to the Medicare contractor who made the initial decision, that contractor’s name and address are right on your denial notice (look for the “Medicare Summary Notice,” or MSN). For a Medicare Advantage or Part D plan, you file directly with your plan.

The form you want is CMS-20027, the standard Redetermination Request form. You can find it at Medicare.gov. That said, you don’t have to use the form, a signed letter with your name, Medicare number, claim details, and a clear explanation of why you disagree works fine. What I always tell people: attach everything. The denial notice, the doctor’s treatment notes, any lab results or imaging reports that support medical necessity. More documentation almost always helps.

One detail I’ve noticed from helping people do this in person: when you submit by mail, send everything certified mail with return receipt. It sounds like overkill, but I’ve seen cases stall because there’s no proof the paperwork arrived. Keep a copy of every single page you send.

The Medicare contractor then has 60 days to issue a decision. If they don’t respond in time, you can actually escalate to Level 2 automatically. That’s a less-known option.

When Things Move Fast: Expedited Appeals

There’s a track for situations where waiting 60 days could seriously harm your health. If you’re being discharged from a hospital and you disagree with the decision, or if your Medicare Advantage plan is denying an urgent service, you can request an expedited (fast) appeal. In those cases, decisions must come within 72 hours.

I’ll be honest: the expedited process is more stressful. You’re usually doing it while you’re sick or while a family member is in a hospital bed. The State Health Insurance Assistance Program (SHIP) can connect you with a free local counselor who can help you file quickly. Call 1-800-MEDICARE (1-800-633-4227) and ask for your SHIP program, or go directly to shiphelp.org. Every state has one. Use it.

A Real Look at What Happens at Level 2

If Level 1 doesn’t go your way, you’re now dealing with a QIC, a Qualified Independent Contractor, which is a third-party reviewer with no financial stake in the outcome. In my experience, this is where having a letter from your doctor really earns its keep.

The QIC has 60 days to decide. They’ll review everything fresh, the original claim, your Level 1 submission, any new documentation you add. Here’s what I’d encourage you to do differently at this stage: ask your doctor to write a letter specifically addressing why the service meets Medicare’s “medical necessity” standard. Not a general clinical note. A letter that speaks directly to the Medicare criteria. That framing matters.

Worked example: A man I’ll call Raymond, a 74-year-old retired teacher in Ohio, was denied home health services after a hip replacement. Level 1 denial was upheld. At Level 2, his physical therapist wrote a half-page letter explaining that Raymond lived alone, had no caregiver, and that without home visits he posed a fall risk under Medicare’s own homebound criteria. Decision reversed. Raymond got 6 weeks of covered home PT.

What About Part D Drug Appeals?

Part D prescription drug coverage has its own parallel appeals process, with slightly different names at each stage. You start with a Coverage Determination request (before a drug is filled) or a Redetermination (after denial). The timelines are tighter: standard decisions within 7 days, expedited decisions within 72 hours.

One thing I genuinely did not understand for my first few years in this work: a formulary exception is technically a type of appeal. If your drug isn’t on your plan’s formulary (the approved drug list), you can request an exception based on medical necessity, and your doctor has to support it. Most people assume formulary is final. It’s not.

Sources

• Centers for Medicare & Medicaid Services (CMS): Official Medicare appeals guidance, forms, and contractor contacts
• CMS Office of Medicare Hearings and Appeals (OMHA): Annual reports on ALJ hearing volumes, timelines, and reversal rates
• Medicare.gov: Beneficiary-facing appeals guide and CMS-20027 form download
• State Health Insurance Assistance Program (SHIP): Free local counseling for Medicare beneficiaries navigating appeals
• Medicare Rights Center, Beneficiary Rights in the Medicare Appeals Process (2025): Policy analysis of denial and reversal trends across all five appeal levels

You came here probably feeling a little stuck. Maybe a little angry. That’s okay. What I want you to leave with is this: that denial letter is not the last word. In 20 years, I’ve never once regretted helping someone appeal. I have, a few times, regretted not pushing someone harder to try.

Photo: MART PRODUCTION via Pexels

This article is for informational purposes only. Medicare rules change annually. Always verify current plan details at Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227). This site does not sell insurance or recommend specific plans.

Recommended Resources

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