How to Appeal a Medicare Decision
🏛️ Your Right to Appeal
If Medicare denies coverage or payment for a service, you have the right to appeal. About 75% of Medicare appeals result in at least partial reversal at some level.
Before You Appeal
Gather Your Documents
- • Medicare Summary Notice (MSN) or Explanation of Benefits (EOB)
- • Denial letter with reason code
- • Medical records supporting your case
- • Doctor's letter explaining medical necessity
- • Any other supporting documentation
Know Your Deadlines
You must file your first appeal within 120 days of receiving your denial notice. Don't wait — start early.
The 5 Levels of Appeal
Level 1: Redetermination
Deadline: 120 days from denial
Your Medicare contractor reviews the claim again. This is the simplest appeal level.
How to file →
- Fill out CMS Form 20027 or write a letter
- Include your Medicare number and claim details
- Explain why you disagree with the decision
- Attach supporting documents
- Send to the address on your denial notice
Level 2: Reconsideration
Deadline: 180 days from Level 1 decision
A Qualified Independent Contractor (QIC) reviews your case with fresh eyes.
How to file →
- Follow instructions on your Level 1 denial
- Submit to the QIC listed on your notice
- Include any new evidence
- Explain why you still disagree
Level 3: Administrative Law Judge (ALJ)
Deadline: 60 days from Level 2 decision
A formal hearing before a judge. Amount must be $180+ (2026).
How to file →
- Request hearing via the OMHA online portal
- Or mail to Office of Medicare Hearings and Appeals
- Hearings can be by phone, video, or in person
- Consider getting help from SHIP or an attorney
Level 4: Medicare Appeals Council
Deadline: 60 days from Level 3 decision
The Appeals Council reviews the ALJ decision. No hearing — paper review only.
Level 5: Federal District Court
Deadline: 60 days from Level 4 decision
Final appeal level. Amount must be $1,840+ (2026). Requires legal help.
Tips for a Successful Appeal
- ✓ File as early as possible — don't wait until the deadline
- ✓ Get a letter from your doctor explaining medical necessity
- ✓ Include all relevant medical records
- ✓ Keep copies of everything you submit
- ✓ Ask your SHIP for free help preparing your appeal
- ✓ Be specific about why the decision was wrong
📞 Free Help with Appeals
Your State SHIP: Find your local program
Medicare Rights Center: 1-800-333-4114
Medicare: 1-800-633-4227