A Medicare denial isn't final: you have the right to appeal it through five levels, starting with a free 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 quarterly statement listing the claims Medicare processed for you. The MSN marks which claims were denied and, in the right-hand margin, gives you appeal instructions and your deadline. 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 Original Medicare appeals
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.
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 the date on your Medicare Summary Notice. The simplest way is to circle the disputed items on the MSN, sign it, and mail it in following the instructions printed on the notice, or file the redetermination request form. 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.
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. By this point most people are working with an attorney, but the right to bring your case before a federal judge is yours.
You don't have to go all five levels. Most appeals end at Level 1 or 2, either because the denial is reversed or because the reader decides the disputed amount isn't worth the next step. The structure is there so you can go as far as your case warrants.
| Level | Who reviews it | Deadline to file | 2026 dollar threshold |
|---|---|---|---|
| 1. Redetermination | Medicare Administrative Contractor (MAC) | 120 days from the Medicare Summary Notice | None |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | 180 days from the redetermination | None |
| 3. ALJ hearing | Administrative Law Judge (OMHA) | 60 days from the reconsideration | At least $200 |
| 4. Appeals Council review | Medicare Appeals Council | 60 days from the ALJ decision | None |
| 5. Judicial review | Federal district court | 60 days from the Council decision | At least $1,960 |
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.
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 moves automatically (for many Part C medical-service denials) or by your request to an Independent Review Entity (IRE), an outside organization that isn't your plan. That's Level 2. 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).
The deadlines on the plan side are generally tighter and faster than Original Medicare's. 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 applying the standard timeline could seriously jeopardize your life, your health, or your ability to regain function. You or your doctor can ask for it. When a physician supports the request, the plan must treat it as expedited.
A standard plan appeal can take days; an expedited one is decided much faster, often within 72 hours. 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 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. The single most common reason appeals fail isn't a weak case, it's a missed date. Mark your deadline the day the denial arrives. If you have a good reason for missing it (a hospitalization, for instance), you can ask for more time by showing "good cause," 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, unbiased counseling on Medicare, including appeals. They can walk you through your specific notice and deadlines at no cost. You can also appoint a representative, a family member, a friend, or an attorney, to handle the appeal for you by filing an Appointment of Representative form.
One special case is worth knowing. If you were kept in the hospital under "observation status" rather than admitted as an inpatient, and that classification cost you Medicare coverage for follow-up skilled nursing care, a court ruling in Alexander v. Azar created a separate right to appeal the status decision itself. That path is distinct from the five levels above; see the observation status guide for how it works.
Frequently asked questions
It depends on the level and the type of coverage. For Original Medicare, you have 120 days from the date on your Medicare Summary Notice to file the first appeal (redetermination), then 180 days for the second level, and 60 days for each level after that. Medicare Advantage and Part D plans run on their own, often shorter, timelines, which your denial notice will state. When in doubt, file as early as you can.
No. Filing a Medicare appeal is free at every level. You may choose to hire an attorney, especially at the higher levels, but you're never charged a fee just to submit an appeal.
It varies by the type of denial and how well it's documented, but appeals are reversed often enough to be worth filing, and a denial reversed early saves you the higher levels. The strongest appeals answer the exact reason for the denial and include support from the doctor who ordered the care. Don't assume a first denial is the final word.
Yes. You can appoint a representative, a family member, a friend, your doctor, or an attorney, to file and manage the appeal on your behalf. You do this by submitting an Appointment of Representative form (CMS-1696) or an equivalent written statement. Your doctor can also support a medical-necessity appeal directly.
A standard appeal follows the normal timeline. A fast (expedited) appeal, available in Medicare Advantage and Part D, is for when waiting could seriously harm your health; it's decided much faster, often within 72 hours. You or your doctor can request it, and when a physician backs the request, the plan must expedite it.
Your State Health Insurance Assistance Program (SHIP) offers free, unbiased Medicare counseling, including help reading your denial notice and filing an appeal. The 1-800-MEDICARE line and Medicare.gov also walk through the steps. None of these charge a fee.
Learn More
- What Is Medicare? Parts A, B, C, and D explained
- Original Medicare vs. Medicare Advantage
- Observation status and your right to appeal a hospital's classification
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.