How do I appeal a decision by Medicare or my plan if they deny coverage for a procedure or medication I need?

Question

Clarence &quot;Mark&quot; Christiansen · Accepted Answer

To appeal a decision by original Medicare, contact Medicare. If your Part D plan is denying prescription drug coverage, have will need to request that your doctor file for a "formulary exception" with your insurance. If the insurance company decision is to deny the requested exception, you need to feel an appeal with your insurance. The recommended plan of action for an insurance company's denial of coverage for a specific procedure is you need to contact your insurance company and file an appeal of the denial. Your independent Medicare health insurance agent (who sold you the plan) most assuredly should be able to help you.

Answered by Clarence "Mark" Christiansen on April 3, 2025

Agent Licensed in WI, AZ, CA & 16 other states

Answered by Clarence "Mark" Christiansen Medicare Insurance Agent

Larry Dalton · Answer

Under traditional Medicare, you will appeal directly to Medicare, and Medicare supplemental/Medigap coverage must follow Medicare's lead in paying your coverage cost. With Medicare Advantage, you will deal directly with the insurance companies that write those plans.

Answered by Larry Dalton on March 26, 2025

Broker Licensed in OK & TX

Answered by Larry Dalton Medicare Insurance Agent

Adam Simon · Answer

You call the plan directly and file an appeal. The number will be on the back of your card. Also, if this is a drug plan, you can request a formulary exception if all other options have been exhausted.

Answered by Adam Simon on March 27, 2025

Broker Licensed in MI, AZ, CA & 7 other states

Answered by Adam Simon Medicare Insurance Agent

Steven Bleicher · Answer

Believe it or not, you have 4 appeals as a member of the Medicare system. The pattern is that you will be declined on your 1st appeal. But on the 2nd one, now they know that you mean business. Once the appeals has been exhausted, you can now file a grievance thru the Medicare website.

Answered by Steven Bleicher on May 14, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Dana Dane · Answer

Please visit the Medicare link listed below for all the details including forms.  I would call your agent for assistance. if you don't have an agent, you could call Medicare.

https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals

Daintee Hurst Dietz · Answer

Your agent can guide you to the department to speak to or call the member services on your card to have someone review decision. I’d recommend you always lean on your agent first. Personal service is always important.

Answered by Daintee Hurst Dietz on June 21, 2025

Agent Licensed in TX

Answered by Daintee Hurst Dietz Medicare Insurance Agent

Fred Manas · Answer

To appeal a Medicare decision denying coverage, first contact the company that handles claims for Medicare (Medicare Administrative Contractor) to understand the reason for the denial. You'll need to file a "Redetermination Request Form" (for Original Medicare) or a "Plan-Specific Form" (for Medicare Advantage) within specific deadlines. Include supporting documentation from your doctor and explain why you disagree with the denial. 
Here's a more detailed breakdown:
1. Understand the Denial:
Get the reason: Call 1-800-MEDICARE or your plan to clarify the denial and what documentation you need. 
Review the Medicare Summary Notice (MSN): This document explains why your claim was denied and how to appeal. 
2. File Your Appeal:
Timely filing: Appeals must be filed within specific deadlines (usually 120 days for Original Medicare and 60 days for Medicare Advantage/Part D, according to United Healthcare and Healthline), from the date on the MSN. 
Redetermination Request Form (Original Medicare): Fill out this form and send it to the Medicare Administrative Contractor listed on the MSN. 
Plan-Specific Form (Medicare Advantage/Part D): Contact your plan for the correct form and instructions. 
Include supporting documents: Gather medical records, doctor's letters, and any other information that supports your need for the service or medication. 
3. Get Help:
State Health Insurance Assistance Program (SHIP): SHIIPs can provide free counseling and help you with the appeals process. 
Medicare.gov: Medicare.gov offers information and resources on appealing coverage decisions. 
4. Further Appeals:
Hearing: If your Redetermination is denied, you can request a hearing with an Administrative Law Judge. 
Medicare Appeals Council: If you are still unsatisfied, you can request a review from the Medicare Appeals Council.

Steve Brauer · Answer

There are different ways to appeal a decision based on what type of Medicare coverage you have, whether that's Original Medicare, or a Medicare Advantage Plan. If you have a good Independent Broker, they should help you appeal any decision that you don't agree with.

Answered by Steve Brauer on April 13, 2025

Broker Licensed in AZ & CA

Answered by Steve Brauer Medicare Insurance Agent

Marcie Barnes · Answer

Contact your plan for assistance on how to file and appeal.  You can also call 1-800-Medicare for assistance on how to file an appeal for Medicare.

Mike Henry · Answer

Got your dr’s office. Get them to refile for you. Make sure they pug the right medical codes in the request.  A lot of times that could be the reason

Deborah Webster · Answer

You can contact your insurance agent to help you file an appeal if you like. If you don't have an agent, you can contact customer service on your health plan and they can help you with the appeal process.

Answered by Deborah Webster on May 12, 2025

Broker Licensed in Ia & SC

Answered by Deborah Webster Medicare Insurance Agent

Tony Hardwick · Answer

You can file an appeal if your plan denies a request. You can also appeal if your plan stops paying or providing for all or part of a healthcare service, supply, item, or prescription drug you think you still need. Make sure your evidence of coverage has the correct information about your claim. Ask your doctor, healthcare provider, or supplier for any information that may help your case. For details about your appeals rights, see your evidence of coverage or contact your insurer.

Answered by Tony Hardwick on April 28, 2025

Agent Licensed in GA, AZ, CA & 15 other states

Answered by Tony Hardwick Medicare Insurance Agent

Randy Hill · Answer

If Medicare or your plan says “no” to paying for a procedure or medicine you need, don’t worry — you can ask them to take another look. This is called an appeal you can politely ask them to review it again.

Here’s how you can appeal, step-by-step:

1. Look at Your Denial Notice:
Medicare or your plan will send you a letter that says they won’t pay. It’s called a "Notice of Denial." Keep this paper — it explains why they said no and tells you how to start an appeal.


2. Ask for a Redetermination (First Appeal):
You’ll need to fill out a simple form or write a letter saying you disagree and why you think they should cover it. Send it to the address listed on your denial notice.
Tip: It’s smart to have your doctor write a note too, explaining why you really need the treatment or medicine.

3. Follow the Deadlines:
You usually have 120 days (about 4 months) from the day you got the denial to file your appeal. So don’t wait too long!

4. What Happens Next:
After you send your appeal, Medicare or your plan has to look at it again and give you an answer. If they still say no, you can keep appealing at higher levels if you want.

Important: Always keep copies of everything you send or get — like letters, forms, and doctor notes — just in case you need them later!

Hope this helps!

Ingrid Kollmann · Answer

Go to ssa.gov and look for an appeal form.  Complete it, including any doctor's notes, and mail/fax/email.

Philip Santucci · Answer

You can try to go to Medicare directly long process and cumbersome. You can try to ask the carrier for assistance some will help. You can also ask your agent if they may be able to assist or lead you in the right direction.

Answered by Philip Santucci on June 5, 2025

Broker Licensed in IL

Answered by Philip Santucci Medicare Insurance Agent

Rodrigo Ferrer · Answer

If at first you don't succeed, try try again.... or file an appeal. If you have a Medicare Part C or Part D plan and something isn't covered or you disagree with a decision, you will file the appeal directly with your insurance carrier. You will get an official letter with steps that must be followed to file an appeal. If that appeal doesn't satisfy you then you can continue to appeal several more times. It's like taking a case all the way to the Supreme Court in a sense. If you were denied directly from Medicare itself then you have to file the instructions on the Summary Notice to appeal. It's a very good idea to always make sure that you support your appeal with any important information that should be known. If your doctor or health care provider can assist with this information, get it! Don't get discouraged and make sure you stand up for yourself. The Medicare appeal system is often underutilized and many people take that initial denial as the final decision. It's not! Fight on!

Answered by Rodrigo Ferrer on May 13, 2025

Broker Licensed in CT

Answered by Rodrigo Ferrer Medicare Insurance Agent

Jacquie Wolf · Answer

It is best to have your medical provider initiate the appeal because they will have to demonstrate the medical need for the service. Many appeals are granted once the medical need is established but certain procedures, like cosmetic or experimental treatments will often be denied.

Answered by Jacquie Wolf on April 8, 2025

Broker Licensed in NY

Answered by Jacquie Wolf Medicare Insurance Agent

Christian Marti Del Campo · Answer

Step 1: Review the Denial Notice

You will receive a denial letter or Notice of Denial of Medical Coverage (for Medicare Advantage) or a Part D Explanation of Benefits. This notice should include:
	•	The reason for the denial
	•	Instructions on how to file an appeal
	•	Deadlines for submitting your appeal

⸻

Step 2: Request a Redetermination (First Level of Appeal)

Original Medicare
	•	Fill out a “Redetermination Request Form” (optional—you can also write a letter).
	•	Send it to the address listed in the denial notice.
	•	You must file within 120 days of the date you received the denial.
	•	A Medicare Administrative Contractor (MAC) will review your case.

Medicare Advantage (Part C) or Part D Drug Plan
	•	You (or your doctor) can request a reconsideration.
	•	Call your plan or submit a written request.
	•	For urgent cases, request an expedited (fast) appeal if waiting could seriously harm your health.

⸻

Step 3: Add Supporting Documentation

It’s helpful to include:
	•	A letter from your doctor explaining why the procedure or medication is medically necessary
	•	Relevant medical records
	•	Any prior approvals or evidence of similar cases being approved

⸻

Step 4: Follow the Appeals Process Through the 5 Levels (If Needed)

If your first appeal is denied, you can continue through these levels:
	1.	Redetermination/Reconsideration by the plan or Medicare contractor
	2.	Review by a Qualified Independent Contractor (QIC)
	3.	Hearing before an Administrative Law Judge (ALJ)
	4.	Review by the Medicare Appeals Council
	5.	Federal District Court Review

Each level has deadlines and procedures, and you’ll be notified how to proceed to the next step if necessary.

⸻

Need Help?
	•	1-800-MEDICARE (1-800-633-4227) — for guidance on appeals
	•	State Health Insurance Assistance Program (SHIP) — free, local help
	•	Your doctor or medical provider — can assist with medical justification
	•	Medicare.gov — has forms and additional details

Sample Medicare Appeal Letter

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