How to Appeal a Medicare Denial

An appeal asks Medicare or your plan to look again at a decision not to pay. A denial letter is hard to read when you need the care now, but it isn't the last word. You ask in writing, by the date on your notice. There are five levels, and each one ends with a letter that says how to go to the next.

You can appeal if

• Medicare or your plan will not pay for care, equipment or a drug you got or need.
• Your plan said no before you got care, which is called a prior approval denial.
• Your hospital, nursing home, home health or hospice care is ending too soon.

Not sure you can appeal? Appeal anyway, because there's no dollar minimum for the first appeal. If you would rather not do it alone, a Pair Team advocate can help you file.

Deadlines for each kind of denial (2026)

Where does a Medicare denial show up?

In Original Medicare, a denial shows up on your Medicare Summary Notice, which isn't a bill. Medicare mails it every 6 months if you had care, and the last page says how to appeal. Call the doctor's office first, because it may have sent the wrong information and can send the claim again.

What are the five levels of appeal in Original Medicare?

1. Redetermination: the Medicare contractor that handled the claim looks again. File within 120 days, with a letter or form CMS-20027 from the Centers for Medicare & Medicaid Services (CMS). CMS is the federal agency that runs Medicare.
2. Reconsideration: a new reviewer, called a Qualified Independent Contractor, looks at it. File within 180 days with form CMS-20033.
3. A hearing with a judge: file within 60 days, and in 2026 at least $200 must still be in dispute.
4. Medicare Appeals Council: if you disagree with the judge, file within 60 days.
5. Federal court: if the Council says no, file within 60 days. In 2026, at least $1,960 must be in dispute, and you may add claims together.

In Medicare Advantage, if your plan says no again, it sends your case to an outside reviewer on its own.

How do I get a fast appeal when a hospital stay or care is ending?

To get a fast appeal, call an outside reviewer, called a Quality Improvement Organization (QIO), at the number on your notice.

• If you're in the hospital, you should get the Important Message from Medicare within 2 days of admission. Call the QIO by the day you're set to go home. You can stay while you wait, and you only pay your usual hospital costs.
• Nursing home, home health, hospice or rehab. You should get a Notice of Medicare Non-Coverage at least 2 days before care ends. Call the QIO by noon the day before.

This works in Medicare Advantage too. For California and New York, the QIO is Commence Health, though older notices may still say Livanta. Call 1-877-588-1123 in California or 1-866-815-5440 in New York (TTY 711). More phone numbers for each state are on Medicare help in California and Medicare help in New York.

How do I appeal a drug plan or Medicare Advantage denial?

To appeal a drug plan or Medicare Advantage denial, start with the plan. For a drug, first ask for a coverage decision, or an exception if the drug isn't on the plan's list. The plan must answer within 72 hours, or 24 hours if your health is at risk. If it still says no, you have 65 days to appeal.

For other care, ask for a fast appeal if waiting could seriously harm your health, and your doctor can ask for you. For a walker or wheelchair, see what Medicare pays for medical equipment.

How to file your appeal

1. Read the notice to find the deadline and the address.
2. Ask your doctor for a letter saying why you need the care, and for copies of your records to send with it.
3. Write your appeal with your name, address and Medicare Number, so they can find your claim. List each item and its date, and say why it should be paid.
4. Mail it to the address on your notice, and keep copies so you can prove what you sent.
5. Watch for the letter, because it says what was decided and what to do next.

Free help with an appeal

• Your State Health Insurance Assistance Program (SHIP): find yours at shiphelp.org or 1-877-839-2675.
• Medicare Rights Center national helpline: 800-333-4114.

What a Pair Team advocate does

A denial often comes at a hard time, like right after a hospital stay, or the week you need a walker. Here's what we do:

• Read the notice with you and find the deadline and where to send it.
• Get the letter and records you need from your doctor.
• Call the QIO with you for a fast appeal if your care is ending.
• Help with what usually comes with it: equipment, rides home, food, utilities and paperwork.

An advocate is covered by Medicare if you qualify. It takes two minutes to find out.

Check if you qualify for a Pair Team advocate

Frequently asked questions

What if I missed the deadline?

If you missed the deadline, you can still ask, because Medicare may accept a good reason for being late, like an illness.

Can someone else appeal for me?

Yes, a family member or friend can appeal for you if you both sign form CMS-1696, the Appointment of Representative.

What if the QIO agrees with the hospital?

If you called in time, you do not pay for the stay until noon the day after the QIO decides. After that, you may have to pay, but you can appeal again.

My hospital changed me from inpatient to observation. Can I appeal?

You can often appeal a change from inpatient to observation. If you were admitted and then changed to observation, you can ask for a fast appeal while you're still there. Your status changes what you pay, and whether Medicare pays for a nursing home stay after.

Is a complaint the same as an appeal?

No, a complaint is not an appeal, because an appeal is about whether Medicare pays. If you're unhappy with the quality of your care, you can file a complaint with the same QIO.

Sources

• Appeals in Original Medicare, Medicare.gov
• Appeals in Medicare health plans, Medicare.gov
• Appeals in a Medicare drug plan, Medicare.gov
• Fast appeals, Medicare.gov
• Medicare Summary Notice (MSN), Medicare.gov
• Appeals Forms, Medicare.gov
• Appointment of Representative, Form CMS-1696, CMS
• First Level of Appeal: Redetermination by a Medicare Contractor, CMS
• Coverage Determinations, CMS
• Commence Health, Medicare BFCC-QIO
• Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024, KFF
• Counseling and Advocacy, Medicare Rights Center
• State Health Insurance Assistance Programs