Medicare Denial Letter: How to Appeal in 5 Steps
Quick answer: A Medicare denial is not the final word. You can appeal at five levels, and the first step is free. For Original Medicare, ask for a redetermination within 120 days of receiving your Medicare Summary Notice. The deadline printed on your own notice is the one that controls. Start with the letter in your hand.
A letter from Medicare saying a service is not covered can feel like the end of the story. It is not. A denial is Medicare's first answer, and you have the right to ask for a second one, then a third, a fourth, and a fifth. The first step costs nothing, and most people never take it because nobody tells them it exists. This page walks the whole ladder in plain English: what the letter means, how to file, how long you have, and the one scam that borrows the appeal's name.
What a Medicare denial letter actually is
For Original Medicare, the denial usually arrives on a Medicare Summary Notice, or MSN. The MSN lists each service, what Medicare paid, and what you may owe, in the column headed "Maximum You May Be Billed." A denied item shows $0 paid by Medicare, and a reason code. The reason code is the short explanation Medicare gives: for example, that the service was not medically necessary, or that a form was missing. Read it first. It tells you what your appeal has to answer.
If you have a Medicare Advantage plan or a Part D drug plan, the denial arrives as a letter from your plan. It explains why the plan denied the request and how to appeal. Keep that letter. The deadline printed on it controls your appeal, and the plan's address for appeals is in it.
A denial is not a bill, and it is not a final decision. It is the first step of a process with five levels, and a different reviewer looks at your case at each one.
The 5-level appeal ladder (Original Medicare)
Each level has its own deadline. Miss one and you can still ask, with a good reason, but the cleanest path is to file on time and let each decision letter point you to the next level.
| Level | Who decides | File by |
|---|---|---|
| 1. Redetermination | Your Medicare Administrative Contractor (MAC) | Within 120 days of receiving your MSN |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | Within 180 days after you get the MAC's decision |
| 3. Hearing | Administrative Law Judge (OMHA) | Within 60 days after you get the QIC's decision |
| 4. Review | Medicare Appeals Council | Within 60 days after you get the judge's decision |
| 5. Judicial review | Federal District Court | Within 60 days after you get the Council's decision |
Levels 1 and 2 usually take about 60 days for a decision. Level 3 needs a case worth at least $200 in 2026. Level 5 needs at least $1,960 in 2026, and you can combine claims to reach it. At every level, the decision letter tells you how to move to the next one.
Level 1, step by step: ask for a redetermination
Level 1 is called a redetermination. It goes to the Medicare Administrative Contractor, a company Medicare hires to review the claim. The people who decide it are separate from the people who made the original decision.
- Read the MSN. Find the denied item and its reason code. Circle it on a copy of the MSN.
- Write why you disagree. One or two plain sentences are enough: what the service was, why your doctor said you needed it, and what the reason code got wrong. A note from your doctor makes the case stronger.
- Fill in your details. Your name and your Medicare Number, the items and dates you are appealing, and the reason you disagree. If you appointed a representative, include a copy of the Appointment of Representative form.
- Send it to the right place. Mail it to the Medicare Claims office address in Step 7 on the last page of your MSN. Or use the Medicare Redetermination Request form, CMS-20027, at CMS.gov/cmsforms/downloads/cms20027.pdf, or call 1-800-MEDICARE (1-800-633-4227) for a copy.
- Keep a copy of everything you send. Every page, every envelope, every note. You will need the paper trail if the case moves up the ladder.
- Wait for the decision. The MAC generally decides within 60 days. If you send more evidence after filing, the MAC gets 14 extra days each time you send more.
- If the MAC says no, go to Level 2. You have 180 days after you get the MAC's decision letter or an MSN to ask a Qualified Independent Contractor for a reconsideration, using form CMS-20033.
If you miss the 120-day deadline, file anyway and explain why in writing. Medicare can excuse a late filing for good cause, such as illness, disability, or an accident.
If you have a Medicare Advantage plan
Your appeal starts with your plan, not with Medicare. First ask your plan for an organization determination if you have not already had one. If the plan denies it, you can ask for a Level 1 reconsideration. You have 65 days from the date on your plan's denial notice to ask, and if you miss it you must give a reason for filing late.
Your plan must decide a pre-service appeal within 30 days, a payment appeal within 60 days, and a Part B drug appeal within 7 days. If waiting could seriously harm your health, ask for a fast appeal: the plan must decide within 72 hours. If the plan upholds the denial, your case goes automatically to an independent reviewer for Level 2, and the same 60-day clocks apply from there up the ladder.
If it is a Part D drug denial
A drug denial has its own path, and it starts with your plan too. First ask for a coverage determination, including an exception if the drug is not on your plan's list or a coverage rule stands in the way. Your doctor must give a supporting statement for an exception.
If the plan denies it, ask for a redetermination within 65 days of the date on the coverage determination notice. The plan must decide a standard benefit request within 7 days and a payment request within 14 days. A fast redetermination takes no more than 72 hours, and only when you have not already paid for and received the drug. From there, the case moves up the same five levels, with 65 days to ask for Level 2.
The fast appeal: when care is ending too soon
If covered care is ending too soon, you do not have to wait for the standard appeal. Hospitals must give you a written notice called An Important Message from Medicare about Your Rights before your stay ends. Skilled nursing facilities, home health agencies, and hospices give you a Notice of Medicare Non-Coverage.
Call the Beneficiary and Family Centered Care Quality Improvement Organization, or BFCC-QIO, named on the notice. For a hospital discharge, the deadline on the notice is usually by midnight of the day you are told to leave. For other care ending, it is usually by noon of the day before your care is set to end. If you do not have the notice, ask for it. The deadline printed on your notice is the one that controls. You can also call 1-800-MEDICARE to get your BFCC-QIO's phone number.
Free help with your appeal
You do not have to do this alone, and you do not have to pay anyone to do it for you.
- Your State Health Insurance Assistance Program (SHIP) gives free, unbiased, one-on-one Medicare counseling in every state, including help with appeals. Call 1-877-839-2675 or visit shiphelp.org.
- Medicare Rights Center runs a free national helpline for coverage problems and appeals. Call 1-800-333-4114.
- 1-800-MEDICARE at 1-800-633-4227 (TTY 1-877-486-2048) can send you the appeal forms and answer questions about your case.
- A representative can act for you: a family member, friend, advocate, attorney, or doctor, appointed with the Appointment of Representative form (CMS-1696) or a written request. Your treating doctor can file a Level 1 appeal for a Medicare Advantage or Part D denial without the form, and must tell you about it.
The scam version: the fee-for-appeal call
An appeal costs nothing at any level. No fee, no payment, no gift card, no bank details, ever. Medicare does not call you unexpectedly about a denial, and it never asks for your Social Security number, Medicare number, or bank details by phone. Medicare already has your information on file.
So when a caller says your claim was denied and offers to file the appeal for a fee, or demands payment to keep your coverage, or asks for your Medicare number to verify the denial, hang up. It is a scam, not Medicare. No fake denial letter campaign has been documented; the trick to watch for is the call that borrows the denial's name. If you want to check a denial, call 1-800-MEDICARE yourself at 1-800-633-4227.
If you already paid someone or shared details
Call your bank first if you shared financial details. Then call 1-800-MEDICARE at 1-800-633-4227 and ask about protecting your Medicare number. Report the call at ReportFraud.ftc.gov and to the HHS Office of Inspector General at 1-800-447-8477. Watch your Medicare Summary Notices for charges you do not recognize. Medicare decides whether a new number is issued, so no one can promise you one.
If the wording of your letter is confusing, our Letter Explainer will read it in plain English, give you a checklist of what to do next, and write a call script you can use when you phone Medicare. It includes a Medicare redetermination letter you can copy and mail. Photograph the letter or paste the text, and it explains it in seconds.
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Check It Now — Free →Frequently asked questions
Is a Medicare denial final?
No. A denial is the start of the appeal process, not the end of it. Original Medicare gives you five levels of appeal, and a Medicare Advantage or Part D plan gives you five levels too. At each level, a different reviewer looks at your case, and each decision letter tells you how to move to the next level.
How long do I have to appeal a Medicare denial?
For Original Medicare, ask for a Level 1 redetermination within 120 days of receiving your Medicare Summary Notice. For a Medicare Advantage or Part D denial, ask for a Level 1 reconsideration or redetermination within 65 days of the date on your plan's denial notice. At every level, the deadline printed on your own notice is the one that controls.
Do I need a lawyer to appeal Medicare?
No. You can appeal on your own, and filing is free at every level. You can also appoint a family member, friend, advocate, or attorney to act for you with the Appointment of Representative form (CMS-1696). Free help is available from your State Health Insurance Assistance Program at 1-877-839-2675 and the Medicare Rights Center at 1-800-333-4114.
What if I miss the appeal deadline?
Do not give up. Ask for the appeal anyway and explain in writing why you were late. Medicare can excuse a missed deadline for good cause, such as illness, disability, or an accident. Act as soon as you can, because the later levels run from the decision dates on your letters.
Can my doctor appeal for me?
Yes. Your treating doctor can file a Level 1 appeal for a Medicare Advantage or Part D denial without a representative form, and must tell you about it. For Original Medicare, your doctor can act for you if you appoint them as your representative with form CMS-1696 or a written request.
What does a fast appeal do?
A fast appeal asks for a decision in 72 hours instead of the standard time, when waiting could seriously harm your health. It also covers care that is ending too soon: if a hospital, nursing facility, home health agency, or hospice says your covered services are ending, call the Quality Improvement Organization named on your notice. For a hospital discharge, that is usually by midnight of the day you are told to leave.
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Sources: Centers for Medicare and Medicaid Services, Medicare Appeals (Publication 11525), medicare.gov; Medicare Rights Center, medicarerights.org; U.S. Attorney's Office, District of Maine, Medicare scams guidance, justice.gov; Federal Trade Commission, ReportFraud.ftc.gov. Last updated November 1, 2026.