Denied by Medicare? How to Appeal & Fight Back

Receiving a denial from Medicare for a healthcare service or treatment you expected to be covered can be frustrating and stressful. However, you have the right to appeal the decision. The Medicare appeals process is structured, and with the right approach, you can challenge a denial successfully. Here’s a step-by-step guide on how to appeal a Medicare claim denial and increase your chances of getting the coverage you need.

Step 1: Understand Why Your Claim Was Denied

Before you begin the appeal process, carefully review the Medicare Summary Notice (MSN) you receive in the mail. This document explains why Medicare denied your claim. Many times, asking a Medicare Agent can help a lot with this identification. Common reasons for denial include:

• The service is considered not medically necessary.

• Medicare does not cover the service.

• The claim contained errors, such as incorrect codes.

• The provider failed to submit proper documentation.

Step 2: Gather Supporting Documentation

To strengthen your appeal, collect any relevant medical records, doctor’s notes, or supporting letters from your healthcare provider. These documents should clearly explain why the treatment or service is medically necessary for your condition.

Step 3: File Your Appeal (Level 1: Redetermination)

You have 120 days from the date on your MSN to file an appeal. Here’s how:

• Complete a Redetermination Request Form (CMS-20027) or write a letter requesting a redetermination.

• Include your Medicare number, the service or item in question, and a detailed explanation of why you believe Medicare should cover it.

• Attach copies of your supporting documents.

• Mail your request to the address provided on your MSN.

Step 4: Appeal to the Reconsideration Level (Level 2)

If your redetermination request is denied, you have 180 days to request a reconsideration by a Qualified Independent Contractor (QIC):

• Complete the Reconsideration Request Form (CMS-20033) or submit a written request.

• Provide additional supporting evidence if possible.

• Mail it to the QIC address provided in your redetermination denial letter.

Step 5: Request a Hearing with an Administrative Law Judge (ALJ) (Level 3)

If the QIC upholds the denial, you can escalate the appeal within 60 days by requesting a hearing before an Administrative Law Judge (ALJ). This step is recommended if the denied claim involves a significant amount of money (at least $180 in 2025).

Step 6: Appeal to the Medicare Appeals Council (Level 4)

If the ALJ rules against you, you can take your case to the Medicare Appeals Council within 60 days. This level involves a more detailed review of your case but does not require a hearing.

Step 7: Federal Court Review (Level 5, Final Step)

If you still don’t receive a favorable decision, and your claim meets the required amount ($1,850 in 2025), you can take your appeal to Federal District Court.

Tips for a Stronger Appeal

• Act quickly. Each appeal level has strict deadlines, so don’t delay.

• Keep records. Save all correspondence, claim numbers, and decision letters.

• Get support. Your doctor, a Medicare agent, or a legal expert can help strengthen your case.

• Be persistent. Many denials are overturned at higher appeal levels.

Final Thoughts

A Medicare denial doesn’t mean the end of the road. By understanding the reasons for the denial, gathering strong evidence, and following the structured appeals process, you can fight back effectively. Don’t hesitate to advocate for your healthcare rights—Medicare appeals exist to ensure you get the coverage you deserve.