Understood Care (04/22/25)

Written by Debbie Hall - Director of Operations at Understood Care | 20+ years of experience in CDPAP program management and home care coordination | Updated February 2026

If Medicare denied your claim, you have the right to appeal. You must file your first appeal within 120 days of receiving your Medicare Summary Notice. According to CMS data, roughly half of all first-level appeals result in the denial being overturned. There are 5 levels of appeal, and you can escalate all the way to federal court if needed.

Key Takeaways

Over 200 million Medicare claims are denied each year, but only 11% of patients file an appeal - and those who do win roughly 80% of the time.
You have 5 levels of appeal, from a simple redetermination to federal court. Most cases are resolved at Level 1 or 2.
The deadline for your first appeal is 120 days from the date on your Medicare Summary Notice. Do not wait.
A letter of medical necessity from your doctor is the single most important document you can include in your appeal.
Free help is available through your State Health Insurance Assistance Program (SHIP) at shiphelp.org or 1-800-MEDICARE.

This article is part of our Complete Guide to Medicare and CDPAP in New York - a comprehensive resource covering Medicare benefits, CDPAP eligibility, caregiver pay rates, appeals, and patient advocacy.

Quick Answer

Medicare denials can be appealed through 5 levels, starting with a Redetermination (120-day deadline). About half of Level 1 appeals succeed, and odds improve at each level. The key: get your doctor's letter of medical necessity, act before the deadline, and do not give up after Level 1.

Getting a denial letter can feel scary. But here is the important thing to know - a denial is not the final word. Medicare has a structured appeals process, and the numbers are in your favor. Many denials get reversed simply because additional documentation was provided that was not included in the original claim.

Let us walk through exactly how the process works, what deadlines you need to hit, and what to include in your appeal to give yourself the best chance of success.

Quick Summary

A Medicare denial is not the final answer. You can appeal.
About half of first-level appeals succeed.
You have 120 days to file (60 days for Medicare Advantage).
Filing an appeal is free. You have nothing to lose.
Call 1-800-MEDICARE or your local SHIP office for free help.

Why Do Medicare Claims Get Denied?

Before jumping into the appeal process, it helps to understand why your claim may have been denied in the first place. The most common reasons include:

Not medically necessary: Medicare decided the service or item was not needed for your condition
Coding errors: The doctor's office or hospital submitted the wrong billing code
Coverage limitations: The service is not covered under your plan (see what Part A and Part B cover), or you have used up your allowed benefit
Missing prior authorization: The service needed pre-approval that was not obtained
Out-of-network provider: You received care from a provider not in your plan's network (Medicare Advantage)
Duplicate claim: A claim was submitted twice for the same service
Timely filing: The provider did not submit the claim within Medicare's deadline

Some of these, like coding errors and duplicate claims, may be fixable without a formal appeal. Call your doctor's billing office first to see if they can correct and resubmit the claim. If that does not resolve it, move to the appeals process.

How to Read Your Denial Notice

Your denial arrives in a document called the Medicare Summary Notice, or MSN, which comes in the mail every 3 months. If you have a Medicare Advantage plan, you will receive an Explanation of Benefits, or EOB, from your plan.

Look for these key pieces of information on your notice:

The specific service or item that was denied
The reason code and explanation for the denial
The deadline to file your appeal
Instructions on where to send your appeal

Keep this notice. You will need to reference it in your appeal letter. If you are having trouble understanding the codes and charges, getting help to analyze your medical bills can make the process much easier.

The 5 Levels of Medicare Appeals

Medicare's appeal system has five levels. You start at Level 1 and can move up if you are not satisfied with the result. Each level is reviewed by a different, independent entity, which gives you a fresh set of eyes on your case.

Level 1: Redetermination

Deadline: 120 days from the date on your MSN

Decision timeline: 60 days for Original Medicare; 30 days for Medicare Advantage pre-service denials

Who reviews it: A Medicare Administrative Contractor, which is the company that processed your original claim

This is your first and most important step. You are asking the same organization that denied your claim to take another look, but a different person reviews it. Here is what to include:

Write a clear appeal letter stating you are requesting a redetermination
Include your name, Medicare number, and the date of the service that was denied
Reference the specific claim number from your MSN
Explain why you believe the service should be covered, in plain language
Attach a letter from your doctor explaining the medical necessity of the service
Include any supporting documents such as medical records, test results, or treatment plans
Make copies of everything before you send it

A letter from your doctor is often the single most important piece of evidence. If your claim was denied as "not medically necessary," your doctor can explain in clinical terms why the service was required for your specific condition.

According to CMS data, roughly half of Level 1 appeals result in a full or partial reversal of the denial. Those are good odds, and they improve when you include strong supporting documentation.

Level 2: Reconsideration by a Qualified Independent Contractor

Deadline: 180 days from the date of your Level 1 decision

Decision timeline: 60 days for Original Medicare; 30 days for Medicare Advantage

Who reviews it: A Qualified Independent Contractor, or QIC, which is completely independent from Medicare

If your Level 1 appeal is denied, you can request a reconsideration. This time, an organization that has no connection to the original decision reviews your case from scratch. You can submit additional evidence at this stage, and you should if you have it.

The instructions for filing Level 2 will be included in your Level 1 denial letter. Follow them carefully and include all documentation from your Level 1 appeal plus anything new.

Level 3: Hearing Before an Administrative Law Judge

Deadline: 60 days from the date of your Level 2 decision

Minimum amount in dispute: $190 for 2026

Decision timeline: 90 days

Who reviews it: An Administrative Law Judge, or ALJ, at the Office of Medicare Hearings and Appeals

At Level 3, you get a hearing where you can present your case, often by phone or video conference. The amount in dispute must meet the minimum threshold of $190 for 2026. You can combine multiple denied claims to meet this amount.

This is where having an advocate or representative can make a real difference. You have the right to bring someone to speak on your behalf, whether that is a family member, a patient advocate, or an attorney. If you feel overwhelmed by the process, learning about patient self-advocacy can help you prepare to present your case effectively.

Level 4: Review by the Medicare Appeals Council

Deadline: 60 days from the date of your Level 3 decision

Decision timeline: 90 days

Who reviews it: The Medicare Appeals Council, part of the Departmental Appeals Board

The Appeals Council can review, modify, or reverse the ALJ decision. They can also send your case back to the ALJ for a new hearing. This level is more of a legal review than a new hearing, so new evidence is generally only accepted if it is relevant and was not available earlier.

Level 5: Federal District Court

Deadline: 60 days from the date of your Level 4 decision

Minimum amount in dispute: $1,850 for 2026

Who reviews it: A federal judge

This is the final level. Very few appeals make it here, but the option exists. You will likely need legal representation at this stage. The amount in dispute must be at least $1,900.

Need Help Filing an Appeal?

Call 1-800-MEDICARE (1-800-633-4227) for free help understanding your denial notice. Or contact your local SHIP office at shiphelp.org for one-on-one guidance through the appeals process.

Appeal Deadlines at a Glance

Appeal Level	Filing Deadline	Decision Within	Minimum Amount
Level 1: Redetermination	120 days	60 days	No minimum
Level 2: Reconsideration	180 days	60 days	No minimum
Level 3: ALJ Hearing	60 days	90 days	$190
Level 4: Appeals Council	60 days	90 days	No minimum
Level 5: Federal Court	60 days	Varies	$1,850

Tips to Strengthen Your Appeal

Whether you are filing at Level 1 or escalating further, these steps give you the best chance of a favorable outcome:

Act quickly. Do not wait until the deadline approaches. The sooner you file, the sooner you get a decision, and the more time you have if you need to escalate.
Get your doctor involved early. Ask your doctor to write a detailed letter of medical necessity. The letter should reference your specific diagnosis, explain why the denied service was needed, and cite any clinical guidelines that support the treatment.
Keep detailed records. Save copies of every document you send and receive. Note the dates of phone calls, the names of people you speak with, and what was discussed.
Be specific in your appeal letter. Reference the exact claim number, date of service, and denial reason. State clearly what outcome you are requesting.
Include all supporting evidence. Medical records, lab results, prescription history, letters from specialists, and photos if relevant. More documentation is better than less.
Request an expedited review if your health is at risk. If delaying the service could seriously harm your health, you can ask for a fast-track decision. Medicare Advantage plans must respond to expedited requests within 72 hours.

What If Your Appeal Is for a Medicare Advantage Plan?

The appeals process for Medicare Advantage plans follows the same five levels, but with some differences in timing and process:

Level 1 decisions come faster, within 30 days for post-service claims and 72 hours for pre-service claims
Your plan must continue providing coverage during the appeal in some situations, particularly if you are currently receiving the service and your plan is trying to stop it
If your plan does not respond by the deadline, your case automatically moves to Level 2

You still have the same right to escalate through all five levels.

When to Get Help With Your Appeal

You do not have to go through this process alone. Free help is available from several sources:

State Health Insurance Assistance Program (SHIP): Every state has a SHIP that provides free Medicare counseling and can help you with appeals
Your state's Medicare ombudsman: They investigate complaints and can advocate on your behalf
Legal aid organizations: If your case reaches Level 3 or higher, legal aid may be able to represent you at no cost
Patient advocates: Professional advocates can review your case, help write your appeal, and represent you at hearings

If you are managing an ongoing health condition and dealing with repeated denials, coordinating your care and paperwork together can reduce the chances of future denials. Our care coordination services can help you stay organized and proactive.

Common Mistakes to Avoid

A few errors can weaken your appeal or cause it to be dismissed entirely:

Missing the deadline. If you file even one day late, your appeal may be rejected. Mark the deadline on your calendar the day you receive your denial.
Not including a doctor's letter. A letter of medical necessity from your treating physician is the strongest piece of evidence you can include.
Using vague language. "I need this service" is not as effective as "This service is medically necessary because my diagnosis of [condition] requires [specific treatment] as supported by [clinical guideline]."
Giving up after Level 1. Many people stop after the first denial is upheld. But each level brings a fresh, independent review. The odds of success increase as you escalate because each reviewer brings a new perspective.
Not keeping copies. If your appeal gets lost in the mail, you need to be able to prove what you sent and when.

Documents You Need for Your Appeal

A complete appeal packet dramatically increases your chances of success. Gather these documents before you file.

Appeal Document Checklist

☐ Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) showing the denial
☐ Letter of Medical Necessity from your treating physician explaining why the service is needed
☐ Relevant medical records - test results, imaging, specialist notes, hospital records
☐ Prior authorization documents (if the denial was for a pre-authorized service)
☐ Your written appeal letter (see sample below)
☐ CMS-20027 form (Medicare Redetermination Request Form) for Level 1 appeals
☐ Appointment of Representative form (CMS-1696) if someone is filing on your behalf
☐ Any supporting clinical guidelines or Medicare coverage determination references (LCD/NCD)

Pro tip: Call your doctor's office and specifically ask for a "letter of medical necessity." Do not assume your medical records alone will be enough. The letter should explain in plain language why the denied service is medically necessary for your specific condition.

Sample Medicare Appeal Letter Template

Use this template as a starting point for your Level 1 appeal. Customize every section with your specific details. A personalized letter is significantly more effective than a generic one.

[Your Full Name]
[Your Address]
[City, State, ZIP]
[Your Medicare Number]
[Date]

Medicare Administrative Contractor
[MAC Name and Address - found on your MSN]

RE: Appeal of Medicare Claim Denial
Claim Number: [Claim Number from MSN]
Date of Service: [Date]
Provider: [Doctor/Hospital Name]
Service Denied: [Description of service]

Dear Medicare Appeals Department,

I am writing to appeal the denial of [specific service/procedure] that was provided on [date] by [provider name]. The denial is referenced on my Medicare Summary Notice dated [MSN date], claim number [number].

Reason for the denial as stated: [Copy the exact denial reason from your MSN]

Why this service is medically necessary:

I have been diagnosed with [condition]. My treating physician, Dr. [Name], determined that [service] was medically necessary because [explain in 2-3 sentences why the service was needed for your specific condition]. Without this treatment, [explain what would happen - worsening condition, increased risk, etc.].

Enclosed with this letter, please find:

1. Letter of medical necessity from Dr. [Name]
2. Relevant medical records and test results
3. [Any other supporting documents]

I respectfully request that you reconsider this denial and approve coverage for the above-referenced service. Please contact me at [phone number] or [email] if you need additional information.

Sincerely,
[Your Signature]
[Your Printed Name]

Important: Send your appeal by certified mail with return receipt requested. This gives you proof of delivery and the date received. Keep copies of everything you send. The MAC must acknowledge receipt within 5 business days.

Original Medicare vs. Medicare Advantage: Different Appeal Processes

The appeals process differs depending on whether you have Original Medicare or a Medicare Advantage plan.

	Original Medicare	Medicare Advantage (Part C)
Level 1 filed with	Medicare Administrative Contractor (MAC)	Your insurance company (the plan itself)
Level 1 deadline	120 days	60 days
Decision timeframe	60 days	30 days (7 days for expedited)
Expedited option?	No standard expedited for Level 1	Yes - 72 hours for urgent/life-threatening cases
Level 2 and beyond	Same as above (QIC, ALJ, etc.)	Independent Review Entity (IRE), then same as Original

Medicare Advantage members: You have a shorter deadline (60 days vs. 120 days) but also a faster decision timeline. If your situation is urgent, request an expedited appeal - your plan must decide within 72 hours.

Watch: How to Appeal a Medicare Denial and Win

This video walks through the Medicare appeal process from start to finish, including how to write an effective appeal letter, what documents to include, and tips for improving your chances at each level of review.

Your Next Step

Got a denial? Here is what to do right now: (1) Find the deadline on your MSN or EOB and write it on your calendar. (2) Call your doctor and ask them to write a letter supporting your case. (3) Call 1-800-MEDICARE or SHIP for free help filing the paperwork.

Key Takeaway

About half of all first-level Medicare appeals are successful. You have nothing to lose by filing - it is free, and you can have a family member or advocate file on your behalf.

Frequently Asked Questions

How long do I have to appeal a Medicare denial?

You have 120 days from the date on your Medicare Summary Notice to file your first appeal (Level 1 Redetermination). For Medicare Advantage plans, the deadline is 60 days from the date on your Explanation of Benefits. Always check the specific deadline printed on your denial notice, as some situations may have different timeframes.

Does it cost anything to file a Medicare appeal?

No. There is no fee to file an appeal at any level. The only financial threshold is the minimum amount in dispute required for Level 3 ($190 in 2026) and Level 5 ($1,900 in 2026). These are not fees you pay - they refer to the dollar amount of the denied claim.

Can I still receive the denied service while my appeal is being reviewed?

In some cases, yes. If your Medicare Advantage plan is stopping a service you currently receive, you can request continued coverage during the appeal by responding within 10 days. If the appeal is ultimately denied, you may owe for services received during the appeal period.

What is the success rate for Medicare appeals?

Approximately half of first-level appeals result in the original denial being fully or partially overturned. Success rates vary depending on the reason for denial and the strength of supporting documentation. Appeals with a detailed letter of medical necessity from the treating physician have a significantly higher success rate than those filed without one.

Can someone else file an appeal on my behalf?

Yes. You can designate a representative to act on your behalf at any level of the appeals process. This can be a family member, friend, doctor, attorney, or patient advocate. You will need to complete an Appointment of Representative form (CMS-1696) and include it with your appeal. Your representative can file paperwork, attend hearings, and make decisions on your behalf.

Key Takeaways

About half of Level 1 appeals result in reversal - always appeal if you believe the denial was wrong.
Your doctor's letter of medical necessity is the single most important piece of evidence.
Each of the 5 levels gets reviewed by a different, independent entity - fresh eyes every time.
Do not miss deadlines. Level 1 is 120 days, Level 2 is 180 days, Levels 3-5 are 60 days each.

The Complete Guide to Medicare and CDPAP in New York for 2026 - Our comprehensive guide covering everything in one place
Medicare Part A vs Part B - What Each Covers - Side-by-side comparison of hospital insurance vs medical insurance, with 2026 costs
What Is CDPAP and Who Qualifies in New York? - Eligibility requirements, income limits, application process, and what services CDPAP covers
How Much Does CDPAP Pay Caregivers in New York (2026)? - 2026 pay rates by region, overtime rules, and how CDPAP compares to agency work
What Does a Medicare Patient Advocate Actually Do? - What advocates handle day to day, when you need one, and how to find one through Medicare

Written by

Debbie Hall

Director of Operations at Understood Care. 20+ years of experience in CDPAP program management and home care coordination across New York.