A Medicare denial usually arrives as a line item, not a letter. On Original Medicare it is a “Medicare denied” note buried on the quarterly Medicare Summary Notice. In a Medicare Advantage plan it is a coverage decision letter. In a Part D plan it is the pharmacy counter saying the drug is not covered and quoting you a cash price. In all three cases the notice is a decision you are entitled to challenge, and the process for doing it is written into federal regulation.
The odds are better than most people assume. KFF’s January 2026 analysis of CMS data found that Medicare Advantage insurers fully or partially denied 4.1 million prior authorization requests in 2024, that only 11.5 percent of those denials were appealed, and that 80.7 percent of the appeals actually filed ended in a partial or full reversal. Every figure below was pulled on September 6, 2026 from Medicare.gov, CMS and the Federal Register.
What Is a Medicare Appeal
A Medicare appeal is a formal request to review a coverage or payment decision. You can appeal a claim Medicare refused to pay, a plan’s refusal to authorize a service or drug before you get it, the amount you were charged for a covered item, and a decision that covered services are ending. Anyone who is a party to the decision can appeal, including the beneficiary, the provider in many cases, and an appointed representative.
Two things this process is not. It is not a complaint about quality of care, which goes to a quality improvement organization on a separate track. And it is not the way to challenge a premium surcharge. If your issue is the income-related monthly adjustment amount added to your Part B and Part D premiums, that is decided by Social Security on form SSA-44 and covered in our guide to the Medicare IRMAA appeal. A late enrollment penalty is likewise a different fight. This page is about coverage and claim denials.
Before you file anything, read the denial reason. Since 2026, Medicare Advantage plans have been required to give a specific reason for a denied prior authorization request, not a generic code. On Original Medicare the reason sits on your Medicare Summary Notice, which is the Medicare version of an explanation of benefits. A denial for missing documentation is a different problem from a denial for medical necessity, and the fix is different too.
The Five Levels of Appeal
Original Medicare Part A and Part B claims run through the ladder below. The deadlines assume the notice was received five days after its date, which is the presumption CMS applies unless you can show otherwise.
| Level | Who decides | Deadline to file | Decision timeframe | 2026 amount in controversy |
|---|---|---|---|---|
| 1. Redetermination | Medicare Administrative Contractor (MAC) | 120 days from receipt of the initial claim determination | 60 days | None |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | 180 days from the redetermination notice | 60 days | None |
| 3. ALJ hearing | Office of Medicare Hearings and Appeals (OMHA) | 60 days from the QIC’s reconsideration notice | 90 calendar days | $200 |
| 4. Council review | Medicare Appeals Council (HHS Departmental Appeals Board) | 60 days from the OMHA decision | 90 calendar days | None |
| 5. Judicial review | Federal district court | 60 days from the Council’s decision | Set by the court | $1,960 |
The $200 and $1,960 figures are the calendar year 2026 thresholds published by CMS in the Federal Register on December 4, 2025. They are recalculated every year against the medical care component of the consumer price index and rounded to the nearest $10, so a threshold you find in an older article is almost certainly wrong. Medicare.gov’s Original Medicare and Medicare Advantage appeals pages both carry the 2026 figures. Its Part D appeals page, as of September 6, 2026, still displays the 2024 threshold of $180, which is one reason to check the Federal Register notice rather than a summary page.
The amount in controversy is not what the provider billed. CMS computes it as the amount charged to you, minus any Medicare payment already made, minus any deductible and coinsurance you would owe anyway. A $500 charge with no Medicare payment and a $100 copayment leaves $400 in controversy. You can also combine claims to clear the threshold.
Levels 1 through 4 are free and paper-based. Level 5 is a lawsuit, with court costs and, realistically, a lawyer. Most beneficiary appeals that succeed do so at level 1 or level 2, which is where new documentation from your doctor does the most work. Our walkthrough on how to appeal a health insurance denial and the templates in our insurance appeal letter guide apply here with one change: address the letter to the entity named on the notice, not to a generic appeals department.
How It Differs by Part
The five levels look the same on paper across Original Medicare, Medicare Advantage and Part D. The clocks do not.
Original Medicare (Part A and Part B). You are almost always appealing after the fact, because traditional Medicare uses prior authorization for only a narrow set of services such as certain outpatient hospital procedures, non-emergency ambulance transport and durable medical equipment. The 120-day and 180-day windows at levels 1 and 2 are the most generous in the whole system. Use them. If the dispute is really about the size of a hospital bill rather than coverage, an itemized hospital bill and the tactics in how to negotiate medical bills often move faster than an appeal.
Medicare Advantage (Part C). Coverage decisions are called organization determinations, and level 1 is a reconsideration by the plan itself. You have 65 days from the date on the denial notice to file, not 120. The plan then has 30 days for a pre-service appeal, 60 days for a payment appeal, 7 days for a Part B drug appeal, and 72 hours for an expedited appeal, with a possible 14-day extension in limited circumstances. If the plan upholds its denial, it must forward the case automatically to an independent review entity for level 2, which is a real structural advantage over Original Medicare. Since January 1, 2026, CMS has also required Medicare Advantage plans to decide prior authorization requests within 7 calendar days for standard requests and 72 hours for expedited ones. See prior authorization and how long prior authorization takes for the mechanics, and Medicare Advantage vs Original Medicare for how the two coverage models differ before you ever hit a denial.
Part D drug plans. These run on the tightest clocks in Medicare. The initial coverage determination is due within 72 hours for a standard request and 24 hours for an expedited one. On an exception request, such as asking the plan to cover a drug that is off its formulary, the clock does not start until the plan receives your prescriber’s supporting statement, so chasing that statement is the single highest-value thing you can do. Level 1, the plan’s redetermination, is 7 days for a benefits appeal, 14 days for a payment appeal, and 72 hours expedited, with 65 days to file. Unlike Medicare Advantage, level 2 is not automatic: you have 60 days to take it to the Part D independent review entity yourself. Our Medicare Part D guide covers what the plan owes you at the counter in the meantime.
If you are still working out which rules apply to you, Medicare parts explained sorts out which program is actually paying.
Fast-Track Appeals
When the dispute is that care is ending rather than that a bill went unpaid, the standard ladder is too slow to matter. Medicare runs a separate expedited track through a Beneficiary and Family Centered Care Quality Improvement Organization, now administered by Commence or Acentra depending on your state.
In a hospital, you should get a notice called An Important Message from Medicare about Your Rights within two days of admission, and again before discharge if the first one came more than two days early. To use it, contact the review organization no later than the day you are scheduled to be discharged. File on time and you can stay in the hospital while the decision is pending, owing nothing beyond your usual coinsurance and deductible. The hospital must then give you a Detailed Notice of Discharge by noon the day after the review organization makes contact, and the decision generally comes within one day of the organization receiving the records it asked for.
In a skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice, the notice is called a Notice of Medicare Non-Coverage and must arrive at least two days before covered services end. The deadline to ask for the fast appeal is noon the day before the termination date on the notice. The provider then supplies a Detailed Explanation of Non-Coverage, and the decision is due by close of business the day after the reviewer has what it needs. These are the fights behind our guides to Medicare home health care coverage and the Medicare hospice benefit.
Miss the fast-track deadline and you can still ask for review, but different rules apply and you may owe for the days past the original end date.
What It Costs and Who Can Help
Filing costs nothing. There is no fee at any of the four administrative levels, no minimum dollar amount at levels 1, 2 and 4, and no requirement to hire anyone.
Free help is real and underused. State Health Insurance Assistance Programs operate in all 50 states plus the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands, and provide one-on-one Medicare counseling at no charge, including help assembling an appeal. The Medicare Rights Center, a national nonprofit, runs a free helpline at 800-333-4114 with counselors who handle denials of care, and its services are available in Spanish.
To let someone else act for you, including a family member or your doctor’s billing office, use form CMS-1696, Appointment of Representative. It is signed by both you and the representative, is valid for one year from signing, and carries through subsequent levels of the same appeal unless you revoke it. As of September 2026, CMS lists an updated CMS-1696 as awaiting approval from the Office of Management and Budget and says the current form, or any conforming written instrument, may be used in the meantime.
Beneficiaries pay nothing for a representative in most cases because SHIP counselors and nonprofit helplines are free. Attorneys who take Medicare appeals typically appear at level 3 or later, where the amount in dispute justifies the cost. If your underlying problem is a surprise charge from an out-of-network provider rather than a Medicare denial, read what balance billing is first, because the remedy there is different.
Bottom Line
Appeal, and appeal early. Level 1 is free, requires no dollar minimum, and gives you 120 days in Original Medicare and 65 days in a Medicare Advantage or Part D plan. Attach the specific clinical documentation the denial reason asks for rather than a general disagreement, and get your prescriber’s supporting statement in fast on any Part D exception, because that is what starts the clock.
Know which clock you are on. If care is being cut off in a hospital, nursing facility, home health agency or hospice, use the fast-track process through the quality improvement organization, not the five-level ladder, and file by the deadline printed on the notice. And if you are anywhere near the third level, confirm the current year’s amount in controversy against the CMS Federal Register notice: for calendar year 2026 it is $200 for an administrative law judge and $1,960 for federal court, and it changes every January.