How to Appeal a Medicare Denial: 5 Levels (2026)

A Medicare denial isn't final: you have the right to appeal it through five levels, starting with a redetermination you can request within 120 days. If Medicare or your plan refused to cover a service, a drug, or a hospital stay, this is how you push back. This guide walks through each level for Original Medicare and for Medicare Advantage and Part D, the deadlines, the 2026 dollar thresholds, and the fast-track appeal for when your health can't wait.

Start by reading the notice

Before you appeal anything, find the document that told you no. Where it comes from depends on how you get your coverage, and it sets your clock running.

If you have Original Medicare (Parts A and B), the denial shows up on your Medicare Summary Notice (MSN), the statement listing the claims Medicare processed for you. The MSN shows which claims were denied, and its last page gives step-by-step directions on how to appeal, along with the date your appeal must be received.1 If you have a Medicare Advantage plan or a Part D drug plan, the denial comes from the plan itself, usually as a letter or a notice called an Integrated Denial Notice or a coverage determination. Either way, the notice is the starting point. It names the service, the reason for the denial, and the window you have to act.

Two things matter most when you read it: the date, because your deadline counts from there, and the stated reason, because your appeal has to answer it. A denial for "not medically necessary" needs a different response than one for a paperwork or coding error.

The five levels of an Original Medicare denial appeal

For Original Medicare, the path is set by the Centers for Medicare and Medicaid Services and laid out on the Medicare.gov appeals page. Here's how each level works, and what you have to do to keep moving.2

Level 1, Redetermination. Your first appeal goes to the Medicare Administrative Contractor (MAC), the company that processed your claim. You file within 120 days of receiving the Medicare Summary Notice that reports the denial, and the notice itself prints the date your appeal must be received. The appeal has to be in writing: circle the items you disagree with on the MSN, explain in writing why you disagree, add your name, phone number, and Medicare number, and mail it with any supporting documents to the claims office address on the notice.1 There's no minimum dollar amount at this level, so any denial qualifies. The MAC generally has 60 days to decide.

Level 2, Reconsideration. If the MAC upholds the denial, you can ask a Qualified Independent Contractor (QIC), a separate reviewer, to take a fresh look. You file within 180 days of the redetermination decision. This is your chance to add anything the first reviewer didn't have: a letter from your doctor, medical records, or a clearer explanation of why the service was needed. The QIC also generally has 60 days to respond.

Level 3, Administrative Law Judge (ALJ) hearing. If the QIC says no, you can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA). You file within 60 days of the reconsideration decision. This is the first level with a dollar threshold: in 2026, the amount in controversy must be at least $200. A hearing is usually held by phone or video, and you can explain your case directly to the judge.2

Level 4, Medicare Appeals Council. If the judge rules against you, you can ask the Medicare Appeals Council, part of the Departmental Appeals Board, to review the decision. You file within 60 days of the ALJ decision. The Council reviews the record and can agree with you, agree with the denial, or send the case back for another look.

Level 5, Federal District Court. The final step is judicial review in federal district court. You file within 60 days of the Council's decision, and in 2026 the amount in controversy must be at least $1,960, though you can combine claims to reach that amount. By this point most people are working with an attorney, but the right to bring your case before a federal judge is yours.2

You don't have to go all five levels. Your case may end at Level 1 or 2, either because the denial is reversed or because you decide the disputed amount isn't worth the next step. The structure is there so you can go as far as your case warrants.

The two dollar thresholds reset each year. The 2026 figures above ($200 to reach a judge, $1,960 to reach court) hold from January 1 through December 31, 2026, so confirm the current amount if your appeal runs into a new calendar year.2

How to tell if your appeal meets the dollar threshold

Both thresholds are measured against the amount in controversy, the amount still in dispute in your appeal. If it is at least $200, your case can go to an Administrative Law Judge at Level 3. To reach federal court at Level 5, it must be at least $1,960, and if a single claim falls short of that, you can combine claims to reach it. The two steps below Level 3 (redetermination and reconsideration) have no minimum at all.2

Appeals in Medicare Advantage and Part D

If you have a Medicare Advantage plan (Part C) or a stand-alone Part D drug plan, your appeal follows the same five-level shape, but the first step is different: you start with your plan, not with a government contractor.

It begins with the plan. Before you can appeal a Medicare Advantage denial, the plan has to make a coverage decision (called an organization determination for Part C, or a coverage determination for Part D). Once the plan denies coverage, your Level 1 appeal is a request that the plan reconsider its own decision. For a Medicare Advantage service, this is a reconsideration; for a Part D drug, it's a redetermination by the plan.

Then an outside reviewer takes over. If the plan upholds its denial, the case goes to an Independent Review Entity (IRE), an outside organization that isn't your plan. That's Level 2. For a Medicare Advantage (Part C) service denial, the plan must forward an adverse reconsideration to the IRE automatically, so you don't have to ask; for a Part D drug denial, you request the IRE review yourself. From there, Levels 3, 4, and 5 are the same as Original Medicare: an Administrative Law Judge at OMHA, the Medicare Appeals Council, and federal district court, with the same 2026 dollar thresholds ($200 and $1,960).2

The deadlines on the plan side can be tighter than Original Medicare's. To ask a Medicare Advantage plan to reconsider a denial, you have 65 days from the date on the plan's denial notice, not 120, and if you file late you have to give a reason.2 The details for drug plans are spelled out on the Medicare drug plan appeals page, and your plan's denial notice will give you the exact dates that apply to your case. Read that notice closely, because plan timelines can run shorter than the Original Medicare windows above.

The fast (expedited) appeal when your health can't wait

Here's the part that matters most when care is urgent. Medicare Advantage and Part D plans must offer an expedited (fast) appeal when waiting for a standard decision could seriously jeopardize your life, your health, or your ability to regain maximum function.2

A standard plan appeal can take days; an expedited one is decided much faster, generally within 72 hours.2 So if you've been denied a drug you need now, or a plan is cutting off a service while you still need it, ask for the fast track and have your doctor say in writing why the delay would harm you. This option exists specifically for situations where the calendar itself is the danger.

How to file a Medicare denial appeal and improve your odds

The mechanics of filing are simpler than the five-level structure makes them sound. A few habits make an appeal stronger.

Hit the deadline, and file early if you can. A missed date can sink an appeal no matter how strong the case is. Mark your deadline the day the denial arrives. In Original Medicare, a missed deadline isn't automatically the end: you can still file and get a decision if you can show "good cause," such as an illness, disability, or accident that delayed you.2 But don't rely on that. File well inside the window.

Get your doctor involved. A denial for "not medically necessary" is answered most powerfully by the person who ordered the care. A letter of medical necessity, your chart notes, and any relevant test results give the reviewer a reason to reverse. Your doctor can also file or support the appeal on your behalf.

Keep copies of everything. Save the denial notice, your written appeal, anything you submit, and proof of when you sent it. If the appeal moves up a level, you'll want the full record in one place.

Get free help. Every state has a State Health Insurance Assistance Program (SHIP) that gives free, personalized, and unbiased counseling on Medicare, including appeals, and it can walk you through your specific notice and deadlines at no cost.4 Find your state's counselor through the national locator at shiphelp.org or by calling 1-877-839-2675. Many states run the program under a different name, such as HICAP, SHINE, or SHICK, so don't be thrown if the office you reach calls itself something else.5 Medicare's own helpline, 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048), is the official national line for beneficiary questions and reaches a real person 24 hours a day, 7 days a week, except some federal holidays.6 If a concern about your case goes unresolved there or with your plan, you can ask the representative to send it to the Medicare Beneficiary Ombudsman, who helps beneficiaries gather the information they need to pursue an appeal. The ombudsman isn't one of the five appeal levels, though, so keep your own appeal deadlines while you wait.7 You can also appoint a representative, such as a family member, a friend, or an attorney, to handle the appeal for you by filing an Appointment of Representative form (CMS-1696) with your appeal.3

One special case is worth knowing. If you were admitted to the hospital as an inpatient and then reclassified to outpatient "observation status" during the stay, and that switch cost you the three-day inpatient stay Medicare requires before it will cover skilled nursing care, the class-action case Alexander v. Azar led CMS to create a separate right to appeal the status change itself, distinct from the five levels above. If the switch was made on or after February 14, 2025, you should get a Medicare Change of Status Notice (CMS-10868) before you leave the hospital, and you or your representative can request a fast appeal through your state's Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), which decides about 2 days after the appeal is filed. If possible it is best to file while you are still in the hospital, but that right does not end at discharge. You still have appeal rights and can ask for an appeal after you leave, following the instructions on the notice, or by contacting your local BFCC-QIO to file if you cannot find it.8 The parallel track for older stays, those admitted between January 1, 2009 and February 13, 2025, closed to new filings on January 2, 2026, so a request there after that date is denied as untimely unless you establish good cause: a valid reason for missing the deadline that was beyond your control, and filing as soon as possible once it was resolved. Good cause isn't automatic; you send a written explanation with evidence, and the request gets a written decision.8 See the observation status guide for who qualifies and how each track works.

Learn More

Find personalized help understanding your Medicare denial and your next appeal step at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.