Medicare Denied You Coverage? What You Need to File an Appeal

Receiving a Medicare denial notice can leave you feeling all at once surprised, frustrated, and worried. You may wonder, Do I have to pay this bill myself? Can I still get the care I need?

A Medicare denial doesn’t necessarily mean you’re out of options. You have the right to appeal when original Medicare, a Medicare Advantage plan, or a Part D drug plan denies future coverage or payment for services already received. An appeal asks Medicare or your plan to review its decision. One study found that while about 17% of Medicare Advantage claims are denied, more than half of these denials are ultimately overturned.¹

Start by understanding the denial, checking your deadline, and gathering information that explains why the service or drug should be covered by your Medicare plan.

How do I prepare to appeal a Medicare denial?

1. Review your denial notice carefully

Find your denial or decision notice and look for these key pieces of information:

• The service, item, or drug denied
• The date(s) of service, if applicable
• Why it was denied
• Whether the decision concerns coverage or payment
• The notice date and appeal deadline
• How and where to submit your appeal

Coverage decisions determine whether Medicare or your plan covers a service, supply, or prescription drug, including one you haven’t received yet. Payment decisions determine whether it will pay for care or prescriptions you’ve already received.

It’s very important to follow the deadline on your specific notice. Don’t assume every Medicare appeal has the same filing period. Be sure to mark the date clearly on your calendar.

If you receive a notice stating that hospital care, skilled nursing facility care, home health services, hospice care, or certain outpatient rehabilitation services are ending when you still need it, you can apply for a fast appeal. 

“Different rules apply in these situations that allow you to challenge that decision quickly,” explained Medicare expert Ryan Ramsey, NCOA Associate Director of Health Coverage and Benefits. “This helps protect your right to extend your care if your doctor feels it’s medically necessary.”

2. Make a list of questions before you contact Medicare or your plan

Knowing exactly why your Medicare claim was denied can help you prepare a strong appeal. If the reason isn’t clear, call 1-800-MEDICARE for original Medicare or contact your Medicare Advantage plan directly for an explanation.

When you call, have your notice handy and ask:

• Why was my claim denied?
• Is this a coverage denial or a payment denial?
• What is my appeal deadline?
• Where and how should I submit it?
• Can I send additional documentation?
• Can my provider submit information for me?
• Can I request an expedited appeal, because waiting could seriously affect my health?

It’s a good practice to make note of every conversation you have about your Medicare denial. Write down the name of the representative you spoke with, their responses to your questions, the date, and the reference number for the call.

3. Determine the correct appeal pathway

How you appeal a Medicare denial depends on whether it came from original Medicare, a Medicare Advantage plan, or a Part D drug plan.

If original Medicare denied coverage

Original (sometimes called traditional) Medicare includes Part A and Part B. Initial claim decisions appear on your Medicare Summary Notice (MSN), a periodic statement that explains how all your claims were handled. The MSN isn’t a bill.

The first level of appeal in original Medicare is called a redetermination, which is a review by the Medicare Administrative Contractor that processed the claim. You have 120 days from the date of receipt of the initial claim determination to request a redetermination. Follow the instructions on your MSN regarding how to appeal a denial.

If Medicare Advantage denied coverage

You can appeal a Medicare Advantage denial through your plan. The first level of appeal is called a health plan reconsideration. Start your appeal by following the instructions on your plan’s denial notice and plan documents. If you haven’t received the service yet and have been denied coverage in advance, your doctor can ask for a reconsideration on your behalf (and they must let you know they’re doing so).

Medicare’s current guidance gives you 65 days from the date on the initial denial notice to file an appeal.

If Medicare Part D denied coverage

Prescription drug coverage has its own appeals process, including when your Part D is rolled into your Medicare Advantage plan.

If a pharmacy says your drug isn’t covered, contact your plan about a coverage determination (its formal decision about coverage or payment). You might need an exception for a drug outside the covered drug list or a restriction, such as a quantity limit. Should that decision not go in your favor, you can request a redetermination, meaning the plan reviews the decision again.

Typically, you’ll have to make a redetermination request within 65 days from the denial notice date. Follow the instructions listed on the written decision notice.

Expedited appeals

If you have Medicare Advantage or Part D and haven’t received the care or medication yet, ask about an expedited appeal if waiting could seriously harm your health. If your plan decides (or your doctor confirms) that waiting could seriously jeopardize your life, health, or ability to regain function, a decision is generally required within 72 hours. Fast appeals aren’t available for reimbursement requests alone.

Original Medicare has different fast-appeal rules for hospital discharge or covered services ending. Follow the instructions and deadlines on your discharge or service-ending notice.

4. Ask your doctor or provider for important information

It’s vital to communicate with your health care provider while you’re preparing an appeal. They can help you understand what was submitted to Medicare and check for billing errors or missing information.

Medicare also recommends asking your provider or supplier for information that could strengthen your appeal and increase your odds of getting the denial overturned. Supporting documentation might include lab and imaging results, treatment plans, progress notes, and a letter from your doctor clearly explaining why this care, treatment, or device is medically necessary for you.

Ask your provider or billing office:

• What service, treatment, or item was billed?
• What diagnosis or medical reason was included?
• Do my medical records clearly explain why I needed this care?
• Was anything submitted incorrectly or left out?
• Can you provide records that support my appeal?
• Can you write a letter explaining why the care was medically necessary?

5. Gather these documents before you appeal

It’s helpful to have everything you need right at your fingertips before you start your appeal. Make sure you have the following:

• Denial or decision notice
• Medicare Summary Notice (for original Medicare)
• Plan documents (for Medicare Advantage or Part D)
• Medical records related to the care
• Bills or statements from your provider
• Provider notes or supporting documentation
• Relevant test results
• Prescription information, for a drug denial
• Letters or messages from Medicare or your plan
• Previous correspondence about the claim
• Medicare number, plan information, and contact details
• Representative information and required authorization, if someone is appealing for you

How to appeal a Medicare denial

Follow the instructions on your denial notice and submit your request before the noted deadline. Your request should include the required forms and information, all supporting documents, and a straightforward explanation of why you disagree with the decision (where you explain this will depend on the plan and type of coverage you have).

For example, on a Medicare Advantage plan’s appeal form, a beneficiary might write something like:  

“I am appealing the denial of coverage for epidural steroid injections for my back pain. Your letter says I did not try physical therapy first, but I completed six weeks of therapy at Woodbridge Physical Therapy in Canton, MA from March 5 to April 16, 2026. My pain is even worse now, and I’m having a hard time walking. My doctor, Dr. Chi, says the injections are the appropriate next step in my treatment plan now that PT and other treatments haven’t relieved my pain. Please see the attached physical therapy discharge notes and my doctor’s supporting letter and approve coverage for the steroid injections.”

Keep copies of everything you submit and write down the dates you submitted them. Save mail and online confirmations, if possible.  

Once you’ve submitted your request for a Medicare appeal, all that’s left to do is await the decision and next steps. The amount of time it takes to get a decision on a Medicare appeal depends on your coverage and the type of appeal you're filing. For level 1 Original Medicare appeals, you should get a decision within 60 days. Decisions on Medicare Advantage pre-service appeals, on the other hand, generally take about 30 days.

What if I miss my deadline for an appeal?

You may still be able to appeal if you have “good cause” for missing the deadline. For instance, a serious illness or accident may have prevented you from filing your Medicare appeal on time. In this case, submit your appeal as soon as possible and explain honestly why it’s late. Medicare or your plan will decide if your reason qualifies for an extension.

What if my Medicare appeal is denied?

Don’t panic—you may still have more paths to explore. The standard Medicare appeals process generally has five levels, although names and procedures differ by coverage. Some later levels have minimum dollar requirements. For example, for a case to receive a judicial review in Federal district court (level 5 appeals), it must meet a minimum dollar amount of $1,960 in 2026.

Check each decision’s instructions and deadlines. For Medicare Advantage, an unfavorable first appeal is automatically forwarded to an Independent Review Entity (IRE) to begin a level 2 appeal. Other pathways may require you to request the next review.

Learn more in NCOA’s guide to starting the Medicare appeals process.

Get help with your Medicare appeal

Navigating a Medicare denial can be time-consuming and confusing, but having the right support can make it less stressful. For help, reach out to:

• 1-800-MEDICARE (1-800-633-4227) for general guidance
• Your local State Health Insurance Assistance Program (SHIP) for free, personalized, unbiased Medicare counseling
• The Medicare Rights Center National Helpline at 1-800-333-4114
• A trusted family member, caregiver, or authorized representative for help organizing and submitting your appeal

You can also visit the Center for Medicare Advocacy website to explore self-help materials that can make filing an appeal easier.

Frequently asked questions (FAQ)

How do I appeal a Medicare denial?
Follow the appeal instructions on your Medicare Summary Notice or plan’s denial notice. Submit your request before the deadline, explain why you disagree, and include supporting documents. Keep copies and proof of submission. The process for filing an appeal depends on whether you have original Medicare, a private Medicare Advantage plan, or Part D.

What is the deadline to file a Medicare appeal?
For a first-level appeal, you have 120 days after receiving an original Medicare claim decision or 65 days from the date on a Medicare Advantage or Part D denial notice. Always follow your specific notice, and keep in mind that appeals involving hospital discharge or services ending can have expedited timelines.

Can my doctor help with my appeal?
Yes. Your doctor can provide your official medical records, correct missing or inaccurate claim information, and write a detailed letter explaining why you needed the care. Depending on your Medicare coverage and appeal type, your doctor may also submit an appeal or support a request for a faster decision.

Who offers free help with Medicare appeals?
Your local State Health Insurance Assistance Program (SHIP) offers free, personalized Medicare counseling and can help you understand your appeal options. Find your local program. You can also call 1-800-MEDICARE (1-800-633-4227) for guidance.

Be your own health care advocate

You deserve to have a voice in your health care, and appealing a Medicare denial is a powerful way to advocate for yourself. Breaking the process down into smaller steps can help make the appeal process more manageable. Start with your denial notice, note your deadline, and ask your provider or local SHIP for help if necessary.

If your out-of-pocket health care costs are weighing on you, visit NCOA’s BenefitsCheckUp. You’ll be connected with benefits programs that may be able to help you afford living expenses like groceries, medicines, utilities. Type in your ZIP code, choose your goal, and find programs and resources that meet your needs.

Source

1. Health Affairs. Medicare Advantage Denies 17 Percent Of Initial Claims; Most Denials Are Reversed, But Provider Payouts Dip 7 Percent. June 2, 2025. Found on the internet at https://www.healthaffairs.org/doi/10.1377/hlthaff.2024.01485