How to Appeal Denied Medicare Claims

Mastering the Maze: Your Definitive Guide to Appealing Denied Medicare Claims

Navigating the complexities of Medicare can be daunting, and few things are as frustrating as receiving a denial for a claim you believed was rightfully covered. It can feel like hitting a brick wall, leaving you confused and worried about unexpected medical bills. However, a denial is rarely the final word. Medicare provides a structured, multi-level appeals process designed to ensure fair consideration of your case. Understanding this process, knowing your rights, and preparing diligently are your keys to overturning denials and securing the coverage you deserve. This comprehensive guide will illuminate every step, empowering you with the knowledge and actionable strategies to confidently appeal denied Medicare claims.

Understanding Why Claims Are Denied: The Root of the Problem

Before diving into the appeal process, it’s crucial to understand the common reasons Medicare claims are denied. Identifying the root cause can help you formulate a stronger appeal and prevent similar issues in the future.

Common Reasons for Denial:

• Lack of Medical Necessity: This is perhaps the most frequent reason for denial. Medicare only covers services and supplies that are “medically reasonable and necessary” for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member.
  • Example: A claim for an experimental treatment that isn’t yet recognized as standard care for your condition, or a procedure deemed elective rather than essential for your health, might be denied for lack of medical necessity.
• Missing or Incorrect Information: Simple administrative errors can lead to immediate denials. This includes incorrect Medicare numbers, missing diagnosis codes (ICD-10), incorrect procedure codes (CPT), wrong dates of service, or incomplete provider information.
  • Example: Your doctor’s office submits a claim with a transposed digit in your Medicare ID number, or they forget to include the specific CPT code for a complex diagnostic test.
• No Prior Authorization: Some services, especially certain durable medical equipment (DME), advanced imaging, or specific medications, require pre-approval from Medicare or your Medicare Advantage plan. If services are rendered without this authorization, the claim will be denied.
  • Example: You receive a specialized wheelchair without obtaining the required prior authorization from your Medicare Advantage plan, leading to the claim being rejected.
• Late or Duplicate Claims: Medicare has strict deadlines for submitting claims. If a claim is submitted past the filing limit, it will be denied. Similarly, submitting the same claim multiple times can also lead to denials for being a duplicate.
  • Example: Your provider’s billing department experiences a backlog and submits your claim for a surgery six months after the service date, exceeding the standard one-year filing limit for Original Medicare.
• Coordination of Benefits (COB) Issues: If you have other insurance in addition to Medicare (e.g., employer group health plan, Medicaid, TRICARE), there’s a specific order in which plans pay. If the claim is sent to the wrong primary payer or there’s a dispute over which insurance is responsible, it can result in a denial.
  • Example: You have Medicare and a former employer’s retiree health plan. The claim is incorrectly sent to Medicare first, when your retiree plan should be the primary payer.
• Service Not Covered by Medicare: Not everything is covered by Medicare. Services considered cosmetic, routine foot care, or certain dental procedures are generally excluded.
  • Example: You undergo cosmetic surgery to remove wrinkles, and the claim is denied because Medicare does not cover procedures solely for aesthetic purposes.
• Non-Participating Provider: While less common with Original Medicare, if you see a provider who has opted out of Medicare, they can charge you more than Medicare-approved amounts. For Medicare Advantage plans, going out-of-network without a referral can lead to denials.
  • Example: You visit a specialist who is not part of your Medicare Advantage plan’s network, and you didn’t obtain a referral from your primary care physician, resulting in the plan denying the claim.

Your Essential First Steps: Preparation is Power

Before initiating any formal appeal, take these crucial preliminary steps to strengthen your case and ensure you’re on the right track.

1. Understand Your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB):

This is your most important document. For Original Medicare, you’ll receive an MSN every three months detailing all services and supplies you’ve received, what Medicare paid, and what you owe. Medicare Advantage plans send an EOB after you receive care.

• Actionable Explanation: Carefully review your MSN or EOB. Look for:
  • The specific item or service denied.

  • The reason code for the denial. This is a numerical or alphanumeric code that explains why the claim was denied (e.g., “service not medically necessary,” “information missing”).

  • The appeal rights and instructions. This section will tell you how to initiate the first level of appeal, including deadlines and contact information.

• Concrete Example: Your MSN shows a denial for a physical therapy session with “Reason Code CO-50: These are non-covered services because this is not considered medically necessary.” This immediately tells you the core of the dispute is medical necessity.

2. Gather All Supporting Documentation:

A successful appeal hinges on providing compelling evidence. This means collecting medical records, doctor’s notes, test results, and any other information that substantiates your claim.

• Actionable Explanation: Contact your healthcare provider (doctor, hospital, clinic, supplier) and request copies of all relevant medical records related to the denied service. This could include:
  • Physician’s orders and referrals.

  • Progress notes detailing your condition, symptoms, and treatment plan.

  • Results of diagnostic tests (X-rays, MRIs, lab tests) and interpretations.

  • Letters of medical necessity from your treating physician.

  • Hospital discharge summaries.

  • Prescription information for medications.

  • Any Advance Beneficiary Notice of Noncoverage (ABN) or Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) you signed. An ABN informs you that Medicare may not cover a service and you might be responsible for payment. If you signed one, it indicates you were notified of potential non-coverage.

• Concrete Example: For the denied physical therapy, you’d request your doctor’s initial referral, notes from the physical therapist detailing your progress and ongoing need for therapy, and any assessments showing functional limitations that necessitate the treatment.

3. Understand the Time Limits:

Each level of appeal has a strict deadline. Missing a deadline can result in the dismissal of your appeal.

• Actionable Explanation: Note the date you received your MSN/EOB and calculate the deadline for your first appeal. Typically, you have 120 days from the date on the MSN for Original Medicare. Medicare Advantage plans may have different deadlines (often 60 or 180 days from the denial notice). Always check your specific plan’s EOB or contact them directly.

• Concrete Example: Your MSN is dated July 1, 2025. You must submit your first-level appeal by October 29, 2025. Mark this clearly on your calendar.

4. Consider an Appointed Representative:

You have the right to appoint someone to act on your behalf, such as a family member, friend, social worker, or attorney. This can be invaluable, especially for complex cases.

• Actionable Explanation: To appoint a representative, you’ll need to complete and submit Form CMS-1696, “Appointment of Representative.” This form formally authorizes someone to discuss your case with Medicare and its contractors.

• Concrete Example: Your daughter, who is well-organized and understands medical billing, wants to help you with the appeal. You fill out and sign Form CMS-1696, designating her as your appointed representative.

The Five Levels of Medicare Appeals: A Step-by-Step Journey

The Medicare appeals process is a hierarchical system with five distinct levels. If you disagree with the decision at one level, you generally have the right to move to the next.

Level 1: Redetermination by the Medicare Administrative Contractor (MAC)

This is the first opportunity to have your claim reviewed. The MAC is the private company that processes Medicare claims.

• What it is: A fresh look at your claim by someone at the MAC who was not involved in the original denial.

• How to file:

  • Original Medicare (Parts A & B): You can either write on your MSN, explaining why you disagree with the decision, and send it back to the address listed. Alternatively, you can use Form CMS-20027, “Medicare Redetermination Request Form.”

  • Medicare Advantage (Part C) or Part D: You request a “Reconsideration” from your plan. Follow the instructions in your plan’s denial notice or Evidence of Coverage.

• What to include:

  • Your name, Medicare number, and contact information.

  • The specific items/services and dates of service you are appealing.

  • A clear, concise explanation of why you believe the claim should be covered.

  • Crucially, all supporting documentation you’ve gathered (medical records, doctor’s letters).

• Deadline:

  • Original Medicare: 120 days from the date you receive your MSN.

  • Medicare Advantage/Part D: Typically 60 days from the date of the denial notice. Expedited (fast) appeals, if your health is at risk, have much shorter deadlines (e.g., 72 hours).

• Timeline for decision: Generally, the MAC (for Original Medicare) or your plan (for Medicare Advantage/Part D) will issue a decision within 60 days of receiving your request. Expedited appeals are much faster (72 hours).

• Concrete Example: Continuing with the physical therapy denial, you write a letter stating, “I am appealing the denial for physical therapy sessions from [dates of service] as marked on my MSN. My physician, Dr. Smith, has documented my need for ongoing therapy to regain mobility after my knee surgery, as shown in the attached medical records and his letter of medical necessity. Without this therapy, my condition will worsen.” You attach all supporting documents and mail it to the MAC address on your MSN.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

If your Redetermination (or plan’s Reconsideration) is denied, you can move to the second level.

• What it is: An independent review of your case by a Qualified Independent Contractor (QIC) for Original Medicare, or an Independent Review Entity (IRE) for Medicare Advantage/Part D plans. These entities are not affiliated with the MAC or your plan.

• How to file:

  • Original Medicare: Use Form CMS-20033, “Medicare Reconsideration Request Form,” or send a written request to the QIC. The denial letter from Level 1 will provide the QIC’s contact information.

  • Medicare Advantage/Part D: Your plan will automatically forward your case to the IRE if they uphold their denial at Level 1.

• What to include:

  • Your name, Medicare number, and contact information.

  • The specific items/services and dates of service.

  • A copy of the Level 1 denial notice.

  • A detailed explanation of why you disagree with the Level 1 decision.

  • Any new or additional supporting evidence that wasn’t submitted at Level 1, or that further clarifies your situation. It’s not necessary to resubmit documents already sent, but you can.

• Deadline:

  • Original Medicare: 180 days from the date you receive the Redetermination decision.

  • Medicare Advantage/Part D: Your plan should automatically forward the appeal. If you need to initiate it, generally 60 days from the date of the plan’s reconsideration decision.

• Timeline for decision: The QIC (or IRE) typically issues a decision within 60 days. For expedited requests, decisions are much faster (72 hours).

• Concrete Example: The MAC denies your physical therapy appeal, stating they still don’t find it medically necessary. You receive the decision on September 15, 2025. You now prepare your request to the QIC, emphasizing new information, such as a recent assessment from your physical therapist showing significant functional improvement directly linked to the therapy, or a specialist’s note recommending continued therapy. You send this to the QIC address provided in the MAC’s denial letter.

Level 3: Hearing by an Administrative Law Judge (ALJ)

This is a more formal stage, where you can present your case in person (or via video/phone) to an independent judge.

• What it is: A hearing before an Administrative Law Judge (ALJ) from the Office of Medicare Hearings and Appeals (OMHA). This is your opportunity to verbally present your case, provide testimony, and potentially have witnesses (like your doctor) testify.

• How to file: You must file a written request using Form OMHA-100, “Request for Administrative Law Judge Hearing or Review of Dismissal,” or a written letter.

• Amount in Controversy (AIC) Threshold: To qualify for an ALJ hearing, the disputed amount must meet a minimum dollar threshold, which changes annually. For example, in 2025, this amount might be around $190. You can combine multiple claims to meet this threshold.

• What to include:

  • Your name, Medicare number, and contact information.

  • The specific items/services, dates of service, and the QIC/IRE reconsideration number.

  • A clear statement of why you disagree with the QIC/IRE’s decision.

  • All previously submitted evidence, plus any new and relevant documentation.

  • Indicate whether you want an in-person, video, or telephone hearing, or if you prefer an “on-the-record” review (where the ALJ decides based solely on the written record without a hearing).

• Deadline: 60 days from the date you receive the QIC/IRE reconsideration decision.

• Timeline for decision: The ALJ generally issues a decision within 90 days of receiving your request.

• Tips for the ALJ Hearing:

  • Prepare your argument: Clearly articulate why the service was medically necessary, how it benefited you, and why Medicare’s denial is incorrect.

  • Organize your evidence: Ensure all your documents are neatly organized and easy to refer to.

  • Consider a witness: Your treating physician, a physical therapist, or even a family member who can attest to your condition and need for care can be powerful witnesses.

  • Be polite and respectful: While it’s a formal proceeding, maintaining a respectful demeanor is important.

• Concrete Example: The QIC denies your appeal, asserting that your physical therapy has reached its maximum benefit. You decide to request an ALJ hearing. Your physical therapy bills, combined, easily exceed the AIC threshold. You work with your physical therapist to prepare a detailed report outlining your progress and the continued necessity of therapy, emphasizing specific functional goals that have not yet been met. You also consider asking your physical therapist to testify at the hearing.

Level 4: Review by the Medicare Appeals Council (MAC)

If the ALJ’s decision is unfavorable, you can seek a review by the Medicare Appeals Council.

• What it is: The Appeals Council, part of the Department of Health and Human Services (HHS) Departmental Appeals Board (DAB), reviews the ALJ’s decision. They can affirm, reverse, modify, or remand (send back for further review) the ALJ’s decision.

• How to file: You must submit a written request for review to the Medicare Appeals Council. The ALJ’s decision will include instructions and the correct address. You can often use Form HA-520, “Request for Review of Hearing Decision/Order.”

• What to include:

  • Your name, Medicare number, and contact information.

  • The specific issues you are appealing from the ALJ’s decision.

  • A detailed explanation of why you believe the ALJ’s decision was incorrect, citing specific facts or legal arguments if possible.

  • Any new evidence that was not previously available.

• Deadline: 60 days from the date you receive the ALJ’s decision.

• Timeline for decision: The Appeals Council generally issues a decision within 90 days.

• Concrete Example: The ALJ upholds the denial, arguing that your medical records don’t sufficiently justify continued therapy beyond a certain point. You meticulously review the ALJ’s decision and identify specific medical reports or professional guidelines that the ALJ may have overlooked or misinterpreted, forming the basis of your argument to the Appeals Council. You might highlight a specific clinical guideline for your condition that supports longer-term therapy.

Level 5: Judicial Review in Federal District Court

This is the final administrative step and involves taking your case to federal court.

• What it is: A lawsuit filed in a U.S. Federal District Court. This is a formal legal proceeding and typically requires legal representation.

• Amount in Controversy (AIC) Threshold: Like the ALJ hearing, there’s a minimum dollar threshold for the amount in controversy to appeal to federal court. This amount is significantly higher than the ALJ threshold and also changes annually (e.g., approximately $1,840 for 2024).

• How to file: You file a civil action in the appropriate Federal District Court.

• What to include: Your legal complaint, outlining the facts of your case, the Medicare Appeals Council’s decision, and why you believe that decision is legally incorrect.

• Deadline: 60 days from the date you receive the Medicare Appeals Council’s decision.

• Considerations: This level is complex and expensive. It’s highly recommended to consult with an attorney specializing in Medicare appeals before pursuing judicial review.

• Concrete Example: The Appeals Council affirms the ALJ’s decision. The amount in controversy still meets the federal court threshold. You consult with an attorney who reviews your entire case file, including all prior appeal decisions and medical documentation, and advises you on the feasibility of pursuing legal action in Federal District Court, weighing the costs and potential outcomes.

Key Strategies for a Successful Appeal

Beyond understanding the steps, employing effective strategies can significantly increase your chances of success.

1. Meticulous Record Keeping:

Maintain a comprehensive file of everything related to your claim and appeal.

• Actionable Explanation: Create a dedicated folder (physical or digital) for your Medicare claims. For each denial, keep:
  • Copies of all MSNs/EOBs.

  • Copies of all appeal requests you submit.

  • Copies of all decision letters you receive.

  • All supporting medical documentation.

  • A log of all phone calls, including dates, times, who you spoke with, and a summary of the conversation.

  • Tracking numbers for mailed documents.

• Concrete Example: When you mail your Redetermination request, you send it certified mail with a return receipt requested. You keep the receipt and tracking number in your file. You also scan all documents into a digital folder with clear filenames like “MSN_July1_2025_ClaimID12345” and “DrSmithLetter_Aug10_2025.”

2. Clarity and Conciseness:

When writing your appeal, be clear, direct, and to the point. Avoid emotional language.

• Actionable Explanation: Focus on the facts. State the denied service, the dates, and why you believe it should be covered, referencing your medical documentation. Use bullet points or numbered lists if it helps organize your thoughts.

• Concrete Example: Instead of writing, “I can’t believe Medicare denied this, it’s so unfair and I really need this therapy,” write, “The physical therapy services provided from [date] to [date] were medically necessary as evidenced by Dr. Jones’s progressive notes, which detail my continued functional limitations and the specific interventions aimed at restoring my mobility post-surgery. The denial fails to acknowledge the documented medical necessity.”

3. Focus on Medical Necessity:

If the denial is for lack of medical necessity, your primary goal is to demonstrate that the service was essential for your health condition.

• Actionable Explanation: Work closely with your doctor. Ask them to write a detailed letter of medical necessity specifically addressing Medicare’s denial reason. This letter should explain:
  • Your diagnosis and current condition.

  • Why the specific service was needed.

  • How it directly relates to your diagnosis and treatment plan.

  • The potential negative consequences if the service is not covered.

  • Reference specific clinical guidelines or medical literature if applicable.

• Concrete Example: Your doctor’s letter for the denied physical therapy clearly states, “Mrs. Johnson’s continued physical therapy is critical for addressing persistent quadriceps weakness (ICD-10 M62.838) and regaining full knee flexion (CPT 97110) following her total knee arthroplasty on [date]. Without this therapy, there is a high risk of permanent functional impairment and a need for further, more invasive interventions.”

4. Timely Filing:

Adhering to deadlines is paramount. Mark them on multiple calendars and set reminders.

• Actionable Explanation: Don’t wait until the last minute. As soon as you receive a denial, begin preparing your appeal. If you anticipate delays in obtaining documents, start that process immediately.

• Concrete Example: Upon receiving your MSN with a denial, you immediately send a request for your medical records to your doctor’s office, knowing it can take a few days or weeks to process.

5. Seek Assistance from SHIP (State Health Insurance Assistance Program):

SHIP counselors offer free, unbiased, and personalized assistance with Medicare issues, including appeals.

• Actionable Explanation: Contact your local SHIP program. They can help you understand your MSN, gather documents, fill out appeal forms, and even prepare for ALJ hearings. They are an invaluable, often overlooked, resource.

• Concrete Example: You call your local SHIP office and schedule an appointment. A SHIP counselor sits with you, reviews your MSN, helps you identify the specific denial reason, and guides you through filling out the Redetermination form and compiling your supporting documents.

6. Don’t Be Afraid to Escalate:

The appeals process is designed with multiple levels for a reason. Don’t give up if your initial appeals are denied.

• Actionable Explanation: Each denial letter will provide instructions on how to proceed to the next level of appeal. Read these instructions carefully and follow them precisely.

• Concrete Example: After receiving a denial at Level 1, you don’t despair. You immediately locate the instructions for Level 2 (Reconsideration by the QIC) in the denial letter and begin preparing for the next step.

Addressing Specific Scenarios

Medicare Advantage (Part C) and Part D Appeals:

While the five-level structure generally applies, there are nuances for Medicare Advantage and Part D plans.

• Organization Determinations: For Medicare Advantage, initial decisions are called “organization determinations.” If your plan denies a service, you first appeal to the plan itself (Level 1: Plan Reconsideration).

• Independent Review Entity (IRE): If your plan upholds its denial, it will automatically send your case to an Independent Review Entity (IRE) for Level 2.

• Expedited Appeals: For both Part C and Part D, if waiting for a standard decision could jeopardize your health or ability to regain maximum function, you can request an “expedited” or “fast” appeal. Your plan must make a decision within 72 hours.

• Grievances vs. Appeals: A “grievance” is a complaint about the quality of care or other concerns, not about coverage denials. Ensure you are filing an appeal for a coverage denial.

Appealing Late Enrollment Penalties or IRMAA Decisions:

Medicare’s appeals process isn’t just for service denials. You can also appeal certain other decisions.

• Late Enrollment Penalties (LEP): If you received a penalty for late enrollment in Medicare Part B or Part D, you can appeal if you believe the penalty was applied incorrectly (e.g., you had other creditable coverage). You’ll need to provide documentation of your prior coverage.

• Income-Related Monthly Adjustment Amounts (IRMAA): If you’re charged a higher Part B or Part D premium based on your income (IRMAA), you can appeal if your income has recently decreased due to certain life-changing events (e.g., marriage, divorce, death of a spouse, work stoppage). You’ll need to provide evidence of the event and your new income.

When to Consider Professional Help

While many appeals can be handled independently, there are situations where professional assistance can be invaluable.

• Complex Medical Cases: If your appeal involves highly technical medical documentation or rare conditions, a medical expert or an attorney specializing in healthcare law can help interpret and present your case effectively.

• High Dollar Amounts: For claims involving significant costs, the investment in professional help might be justified by the potential financial savings.

• Judicial Review (Level 5): Appealing to Federal District Court almost always requires legal representation due to the complex legal procedures involved.

• Overwhelmed or Unable to Navigate: If the process feels too daunting, confusing, or you are too ill to manage it yourself, appointing a representative or seeking help from a legal aid organization or a private attorney is a wise decision.

A Powerful Conclusion: Your Right to Coverage

Being denied Medicare coverage for a necessary service can be disheartening, but it is not a dead end. Medicare’s multi-level appeals process is your fundamental right, a mechanism designed to ensure that you receive the benefits you are entitled to. By understanding the reasons for denials, meticulously preparing your case, gathering compelling evidence, adhering to strict deadlines, and strategically escalating your appeal through each level, you dramatically increase your chances of success.

Empower yourself with knowledge, leverage available resources like SHIP, and remember that persistence often pays off. Your health and financial well-being depend on it. Don’t let a denial deter you; instead, view it as an opportunity to advocate for yourself and secure the Medicare coverage that you have earned.