How to Appeal a Medicare Denial: The 5 Levels of Appeal Explained

Why the Medicare Appeals Process Matters

If Medicare or your Medicare Advantage plan denies coverage for a service, drug, or hospital stay, you have the legal right to appeal. The Medicare appeals process is a structured, five-level system that gives you multiple chances to challenge a denial with an independent reviewer at each stage. Many denials are reversed simply because the beneficiary submitted missing paperwork or a stronger explanation of medical necessity.

The process applies to Original Medicare (Parts A and B), Medicare Advantage (Part C), and Part D prescription drug plans, though the timelines and first-level entry point differ for each. Regardless of which type of coverage you have, the same five-level structure eventually converges at the Administrative Law Judge (ALJ) level and beyond.

The 5 Levels of Medicare Appeal at a Glance

Here is the full ladder of appeal levels for Original Medicare, along with the 2026 deadlines and dollar thresholds.

The 2026 amount-in-controversy thresholds of $200 for ALJ hearings and $1,960 for federal court review took effect January 1, 2026, and are adjusted annually based on the medical care component of the Consumer Price Index.

Level 1: Redetermination by the MAC (Form CMS-20027)

The first step for an Original Medicare denial is a redetermination by the Medicare Administrative Contractor (MAC) that processed your original claim. You have 120 days from the date you received your Medicare Summary Notice (MSN) or denial letter to file. Medicare presumes you received the notice five calendar days after the date printed on it.

How to file with CMS-20027

The official form is CMS-20027, Medicare Redetermination Request Form. You can also submit a written request without the form, as long as it contains all the required information.

Your redetermination request must include:

• Beneficiary name and Medicare number
• The specific item or service being appealed
• Date(s) the service was received
• Date of the initial determination notice
• A written explanation of why you disagree
• Supporting documentation (medical records, letter of medical necessity)

Send the completed form to the MAC address printed on your MSN. The MAC typically issues a decision within 60 days of receiving your appeal.

Level 2: Reconsideration by a QIC

If the MAC upholds the denial, you can request a reconsideration by a Qualified Independent Contractor (QIC), which is a company independent of the MAC. You have 180 days from the date of the MAC's redetermination decision to file. Use form CMS-20033 or submit a written request.

This is your last chance to add new evidence easily. After Level 2, any new documentation generally must meet a "good cause" standard to be accepted. Submit everything the QIC needs to reverse the denial: physician letters, medical records, imaging, and citations to any relevant Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs).

The QIC typically issues its decision within 60 days. There is still no minimum dollar amount required at this level.

Level 3: Administrative Law Judge (ALJ) Hearing

If the QIC's decision goes against you, you can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA). This is the first level with a dollar threshold: for requests filed on or after January 1, 2026, at least $200 must remain in controversy. You can combine multiple claims to meet this amount.

You have 60 days from the date of the QIC decision to file. Hearings are usually conducted by phone or video conference, and OMHA aims to issue a decision within 90 days, though real-world wait times have historically been longer.

At the ALJ level, appeals become more formal. You may want to consider representation by an attorney, patient advocate, or family member (with an Appointment of Representative form on file).

Level 4: Medicare Appeals Council Review

If the ALJ rules against you, you can ask the Medicare Appeals Council, part of the HHS Departmental Appeals Board, to review the decision. You have 60 days from the ALJ decision to file. There is no additional dollar threshold at this level because the ALJ threshold already had to be met.

The Council can affirm, reverse, modify, or remand the ALJ's decision. It may issue a written decision on the record without a new hearing.

Level 5: Federal District Court Review

The final level is judicial review in a U.S. Federal District Court. You have 60 days from the Appeals Council decision (or notice that the Council declined to review) to file. For 2026, at least $1,960 must remain in controversy to sustain this level of appeal.

At this stage you are filing a federal lawsuit against the Secretary of Health and Human Services, and legal representation is essentially required.

Original Medicare vs. Medicare Advantage vs. Part D Appeals

Although all three coverage types eventually converge at the ALJ, Appeals Council, and federal court levels, the first two levels look different for each.

Medicare Advantage (Part C) appeals

• Filing window: 60 to 65 days from the plan's denial notice
• Standard decision time: 30 days for pre-service, 60 days for payment appeals, 7 days for Part B drugs
• Expedited decisions: 72 hours for urgent care
• Auto-escalation: If the plan misses its deadline or upholds the denial, the case is automatically forwarded to the Part C Independent Review Entity (IRE)

Part D drug plan appeals

• Filing window: 65 days from the coverage determination
• Level 1 (plan redetermination): 7 days for benefits, 14 days for payment
• Expedited urgent drug decisions: 24 to 72 hours
• Level 2: Handled by the Part D Independent Review Entity

Fast (Expedited) Appeals for Hospital Discharge and Urgent Drugs

If you are being discharged from a hospital, skilled nursing facility, home health, or hospice and you disagree, you can file an expedited appeal through a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The two national QIO contractors are Livanta and Acentra Health, and which one serves you depends on your state.

How the hospital discharge fast appeal works

1. When you are admitted, the hospital gives you the Important Message from Medicare (IM) with your QIO's contact number.
2. To trigger a fast appeal, you must call the QIO by midnight of the day of your scheduled discharge, while still in the hospital.
3. The hospital must send the QIO a detailed notice of why they believe you are ready to leave, along with your medical record.
4. The QIO reviews the case and typically issues a decision within one calendar day of getting the required records.
5. While the QIO reviews, the hospital cannot force you to leave and Medicare continues to pay.

If you win, Medicare keeps paying. If you lose, you can be billed for any hospital costs starting at noon the day after the QIO's decision. You can also request an expedited reconsideration from the QIC, typically by noon of the next calendar day.

Expedited Part D drug appeals

If a Part D plan denies a drug you urgently need, you or your doctor can request an expedited coverage determination or redetermination. The plan must decide within 24 to 72 hours if delay could seriously jeopardize your health.

Sample Medicare Appeal Letter Outline

Whether you are appealing to a MAC, a Medicare Advantage plan, or a Part D plan, an effective appeal letter follows the same structure.

Header:

• Your name, address, phone, Medicare number
• Date
• Addressee (MAC redetermination department or plan appeals department)
• Subject line: "Request for Redetermination – Denial of [Service] on [Date]"

Section 1 – Background: Your age, relevant diagnosis, and the treating physician who ordered the service.

Section 2 – Denial reason: Quote the exact denial language from your MSN or denial letter, then state that you disagree.

Section 3 – Medical necessity argument: Explain in plain terms why the service or drug is medically necessary. Reference the attached Letter of Medical Necessity from your doctor.

Section 4 – Coverage policy: Cite any applicable LCD, NCD, or plan medical policy that supports coverage in your situation.

Section 5 – Supporting evidence list: Enumerate the attached documents (medical records, imaging, physician letters, prescriptions, guidelines).

Section 6 – Requested action: Ask for the specific relief ("Please reverse the denial and pay the claim for [service] on [date].").

Signature and enclosures.

Tips for Winning Your Medicare Appeal

Additional winning strategies:

• Send everything by certified mail with return receipt so you can prove timely filing.
• Keep a call log with dates, names, and reference numbers for every conversation.
• Aggregate related claims to meet dollar thresholds at the ALJ and federal court levels.
• Do not stop after one denial. Success rates typically improve at Levels 2 and 3, especially when your file is well documented.
• Get free help from your State Health Insurance Assistance Program (SHIP) counselor.

Frequently Asked Questions

How long does a Medicare appeal take?

For Original Medicare, a Level 1 redetermination decision typically arrives within 60 days of filing, and a Level 2 QIC reconsideration also takes about 60 days. An ALJ hearing is targeted at 90 days but has historically taken much longer due to backlogs. Medicare Advantage decisions are faster: 30 days for standard pre-service appeals and 72 hours for expedited ones.

What is the deadline to file a Medicare appeal?

The deadline depends on which coverage you have and which level. For Original Medicare Level 1, you have 120 days from your denial notice; for Medicare Advantage and Part D, you have 60 to 65 days for the first level. At Levels 3, 4, and 5, all three programs use a 60-day filing window from the previous decision.

What is Form CMS-20027 used for?

CMS-20027 is the official Medicare Redetermination Request Form used for Level 1 appeals of Original Medicare claim denials. You file it with the Medicare Administrative Contractor (MAC) that processed your original claim, within 120 days of your denial. If you prefer, you can submit a written letter instead, as long as it contains the same required information.

Who are Livanta and Acentra Health?

Livanta and Acentra Health are the two national Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) that handle expedited Medicare appeals for hospital discharges, skilled nursing facility terminations, and similar time-sensitive coverage decisions. Which one serves you depends on the state where you receive care. Their contact information is printed on the Important Message from Medicare you receive when admitted to a hospital.

What is the 2026 dollar threshold to appeal to federal court?

For requests filed on or after January 1, 2026, at least $1,960 must remain in controversy to sustain an appeal to federal district court. The threshold for reaching an Administrative Law Judge hearing is $200. These amounts are updated each year based on the medical care component of the Consumer Price Index, and multiple claims can often be combined to reach the threshold.