Medicare denied my care — what do I do?
In 2024, Medicare Advantage insurers issued 53 million prior-authorization determinations and denied 7.7% of them — about 4.1 million services. Only 11.5% of those denied beneficiaries appealed. But of the ones who did, 80.7% won.
The math is brutal: roughly 3.6 million care events per year are abandoned by beneficiaries who didn't know to appeal — even though the insurer was wrong about four out of five times. This page walks you through the five-level appeal ladder, what wins at each level, and exactly where to start.
Before anything else — read the denial notice
By federal regulation (42 CFR 422.568, 423.568), every Medicare denial notice must include:
- The exact service or drug being denied
- The specific reason
- The address and fax to send your appeal
- Your deadline (always 60 days from the date of the notice)
- Whether you can request expedited review
The reason matters most: “not medically necessary” is appealed differently than “not covered under the formulary” or “out-of-network.” Photograph every page of the notice and the original prescription or order.
The 5-level appeal ladder
Medicare Advantage (Part C) and Part D each have a five-level ladder, mostly mirrored. Most appeals end at level 1 or 2 — 80.7% win at the plan level. The higher levels are reserved for cases worth fighting longer.
Reconsideration / Redetermination
- Decided by
- The plan itself
- Filing deadline
- 60 days from the denial notice
- Decision target
- 30 days standard / 72 hours expedited (Part C); 7 days / 72 hours (Part D)
- Success rate
- ≈80% of appealed cases
- Citation
- 42 CFR 422.578 (Part C) / 423.580 (Part D)
This is where you start. The plan reviews its own decision, usually with a different person than made the original call. Adding a one-paragraph supporting statement from your doctor flips the success rate dramatically — formulary exceptions win ~15% without it, ~70% with it.
Independent Review Entity (IRE)
- Decided by
- A CMS contractor (MAXIMUS Federal Services)
- Filing deadline
- 60 days from the level-1 denial — but Part C plans must auto-forward; Part D plans do NOT auto-forward
- Decision target
- 30 days standard / 72 hours expedited (Part C)
- Success rate
- ≈25–35% of cases reaching this level
- Citation
- 42 CFR 422.590(b) (Part C auto-forward) / 423.600 (Part D self-file)
For Medicare Advantage, the plan auto-forwards your case if it upholds its own denial — you don't file again, but you should send the IRE any new evidence within 10 days. For Part D, you have to file with the IRE yourself — the plan's denial letter will include the IRE's contact info.
Administrative Law Judge (ALJ)
- Decided by
- A federal Office of Medicare Hearings and Appeals (OMHA) judge
- Filing deadline
- 60 days from the IRE decision
- Decision target
- 90 days target (often longer in practice)
- Success rate
- ≈15–25% of ALJ-level cases
- Dollar threshold
- A minimum dollar threshold applies — set annually by HHS, around $190 for 2025; check the SSA Federal Register notice for 2026
- Citation
- 42 CFR 422.602 / 423.610
You can request a hearing by phone or video — most cases are decided without an in-person appearance. You can represent yourself or use a lawyer (pay them out of any recovered benefits). This is where Disability Rights Wisconsin (1-800-928-6727) becomes valuable for free legal help.
Medicare Appeals Council
- Decided by
- The HHS Departmental Appeals Board
- Filing deadline
- 60 days from the ALJ decision
- Decision target
- 90 days target
- Success rate
- Low — most ALJ decisions stand
- Citation
- 42 CFR 422.608 / 423.620
A paper-only review of the ALJ's decision. The Council can affirm, reverse, modify, or send the case back. Worth pursuing only when you have a clean legal argument the ALJ may have misapplied.
Federal District Court
- Decided by
- A federal judge
- Filing deadline
- 60 days from the Council decision
- Decision target
- No fixed timeline
- Success rate
- Case-specific; rare
- Dollar threshold
- Higher dollar threshold than ALJ — typically ≈$1,840 for 2025; check the SSA Federal Register notice for 2026
- Citation
- 42 CFR 422.612 / 423.630
Hire a lawyer. Filing fees apply. Federal court appeals are uncommon — most beneficiaries who get this far have a consequential systemic issue, not a single denied service.
Three things that win appeals at level 1
For Part D formulary exceptions, this is the single largest factor. ~15% success without it, ~70% with it. Ask your doctor's office to fax a one-paragraph letter on letterhead saying the drug is medically necessary and alternatives have been tried or contraindicated.
The Evidence of Coverage (EOC) book your plan mailed you spells out exactly what's covered and under what conditions. If the denial contradicts the EOC, quote the EOC chapter and section in your appeal. CMS requires plans to honor their own published rules.
Plans count from the date on the notice, not the date you opened the envelope. Late appeals get rejected on procedure regardless of merit. If you're close to the deadline, send by certified mail or fax with a receipt — keep a copy of everything you send.
When to ask for expedited review
The standard timeframe is 30 days for MA reconsideration and 7 days for Part D redetermination. If waiting that long could seriously jeopardize your health, life, or ability to regain function, you can request expedited review — decision in 72 hours (MA) or 24 hours (Part D after prescriber statement). Common cases that qualify: an ongoing prescription that prevents stroke, a hospital discharge dispute, post-surgical home health that prevents readmission. The appeal letter generator at /appeals has a checkbox for expedited that adds the right legal language and citation to your letter.
Free help in Wisconsin
State Health Insurance Assistance Program — free, neutral Medicare counseling. Will help you read the notice and decide whether to appeal.
1-800-242-1060Free legal representation for Medicare appeals at any level, especially helpful at ALJ and beyond. Income limits don't apply for Medicare cases.
1-800-928-6727National Medicare helpline — useful for procedural questions about the appeals process and for navigating multi-state issues.
1-800-333-4114CMS's general line. They can confirm your appeal was received and at which level, and tell you the status of ALJ and Council cases.
1-800-633-4227Ready to draft the letter?
Our appeals tool fills in the legally-required language, the right CFR citation, and the timeframe expectation based on whether you're asking for expedited review. Edit it to match your situation, copy it, and send to the address on your denial notice.
Sources: KFF Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024; Medicare Rights Center 2024 Helpline Trends Report; 42 CFR Parts 422 (Part C) and 423 (Part D); CMS Office of Medicare Hearings and Appeals.