By Christian BrinkleyLicensed NC Insurance Agent, NPN 22217190, NC Life & Health · Updated October 14, 2026 · 4 min read
Your Medicare Advantage plan denied a service, a test, or a drug your doctor ordered. That denial is not the final word. Medicare gives you a formal appeals process with multiple levels. Many denials get reversed on appeal, especially when the medical record supports the request. The key is acting fast and following the process exactly. Miss a deadline and you lose the level. Here is how it works.
Step 0: Understand What You Got
When your plan denies coverage, it must send you a written notice explaining the denial and your appeal rights. Read it. It tells you what was denied, why, and how to appeal. Keep this notice. It is the foundation of everything that follows.
Level 1: Reconsideration by the Plan
Your first appeal goes back to your plan. This is called a request for reconsideration. You are asking the plan to take another look.
You generally have 60 days from the date on the denial notice to file. You can file by following the instructions on the denial notice. Most plans accept appeals by mail, fax, and sometimes through an online portal.
Level 2: Independent Review Entity
If the plan upholds its denial, your case automatically goes to an independent review entity. You do not have to file this yourself. The plan forwards it.
The independent reviewer looks at your case fresh. They are not part of your plan. This level reverses a meaningful share of denials, because the reviewer applies Medicare coverage rules without the plan's cost incentives.
The reviewer must decide within the timeframes Medicare sets. For standard cases, that is generally 30 days for pre-service and 60 days for post-service. You will get a written decision.
Level 3: Administrative Law Judge Hearing
If the independent reviewer upholds the denial and the amount in dispute meets a minimum dollar threshold, you can request a hearing before an administrative law judge. The threshold changes yearly, so check medicare.gov for the current figure.
You have 60 days from the independent review decision to request the hearing. The hearing can be by phone, video, or in person. You can represent yourself, bring a representative, or have your doctor testify.
This level takes longer. Backlogs are real. But the judge applies the law to your facts, and this is where well-documented cases often win.
Level 4: Medicare Appeals Council
If the judge rules against you, you can ask the Medicare Appeals Council to review the decision. You have 60 days to request this review. The Council looks at whether the judge applied the law correctly.
You do not get a new hearing at this level. The Council reviews the record. New evidence is generally not accepted unless you show good cause for not submitting it earlier. That is why building your record early matters.
Level 5: Federal District Court
The final level is federal district court. This is available if the amount in dispute meets a higher threshold, which changes yearly. You have 60 days from the Council's decision to file.
Very few cases reach this level. But the option exists, and it matters for high-cost denials like major surgeries or expensive ongoing treatments.
How to Strengthen Any Appeal
Start with the denial letter. Understand the exact reason. Plans deny for specific reasons: not medically necessary, experimental, not covered under your plan's rules. Your appeal must answer the specific reason.
Get your doctor involved early. A letter that says “this is medically necessary” helps. A letter that explains why, citing your diagnosis, failed alternatives, and clinical guidelines, wins cases. Ask your doctor to reference the specific Medicare coverage criteria if they know them.
The Bottom Line
This article is for general information only and is not legal, tax, or insurance advice. Appeal timeframes and thresholds change, so verify current rules on medicare.gov. For free, unbiased help with an appeal, contact your State Health Insurance Assistance Program (SHIP), call 1-800-MEDICARE, or talk with a local licensed insurance agent.
Questions people ask me about this
What should I know about the plan?
Your first appeal goes back to your plan. This is called a request for reconsideration. You are asking the plan to take another look. You generally have 60 days from the date on the denial notice to file. You can file by following the instructions on the denial notice.
How do I strengthen any appeal?
Start with the denial letter. Understand the exact reason. Plans deny for specific reasons: not medically necessary, experimental, not covered under your plan's rules. Your appeal must answer the specific reason. Get your doctor involved early. A letter that says “this is medically necessary” helps.
What should I know about step 0?
When your plan denies coverage, it must send you a written notice explaining the denial and your appeal rights. Read it. It tells you what was denied, why, and how to appeal. Keep this notice. It is the foundation of everything that follows. There are two kinds of denials.
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