If your Medicare Advantage plan denies coverage for a product, service, or medication, you have the legal right to appeal that decision. Denials are not always the final word. Many appeals are successful, especially when you submit strong documentation from your doctor. Here is a plain-language guide to every step of the Medicare Advantage appeals process.
Why Plans Deny Claims
Medicare Advantage plans must cover everything that Original Medicare covers, but they can require you to follow certain rules to access that coverage. Common reasons for denial include:
- Insufficient documentation of medical necessity
- Using an out-of-network provider without prior authorization
- The plan considers the item or service experimental or not medically necessary
- Missing prior authorization before a procedure or purchase
- The plan believes a less expensive alternative is appropriate
For durable medical equipment (DME) denials, the most common reason is that the paperwork did not adequately document why the item is medically necessary. A stronger letter from your doctor can often reverse a denial at the first level of appeal.
Level 1: Redetermination (Your Plan Reviews the Denial)
The first step is to request a redetermination from your Medicare Advantage plan. This means asking the plan to take a second look at your case. You must submit your written request within 60 days of the date on your denial letter.
To request a redetermination:
- Write a letter that uses the word "appeal" explicitly. State your name, your member ID number, what was denied, and why you believe coverage should be approved.
- Ask your doctor to write a letter of medical necessity. This is the single most important document in a DME or service appeal. The letter should explain your diagnosis, why the requested item or service is medically necessary, and what could happen without it.
- Attach any relevant medical records, test results, or doctor notes that support your case.
- Keep a copy of everything you send.
- Send the appeal by certified mail or through your plan's online appeals portal so you have proof of submission.
Your plan must respond within 60 days for a standard appeal. If your health situation is urgent, request an expedited appeal in writing and the plan must respond within 72 hours.
Level 2: Reconsideration by an Independent Reviewer
If your plan upholds the denial after the redetermination, you can request reconsideration by a Qualified Independent Contractor (QIC). The QIC is a third-party organization that reviews appeals independently from your plan.
You must request reconsideration within 60 days of your plan's redetermination decision. Submit the same documentation you used in Level 1, and add any new evidence your doctor can provide. The QIC must respond within 60 days for a standard appeal or 72 hours for an expedited appeal.
Level 3: Administrative Law Judge Hearing
If the QIC also denies your appeal and the amount in dispute is $180 or more (adjusted annually), you can request a hearing before an Administrative Law Judge (ALJ). You must request this within 60 days of the QIC's decision.
An ALJ hearing gives you the opportunity to present your case in person or by phone. You can bring your doctor or a representative to speak on your behalf. ALJ hearings result in reversal more often than plan-level reviews, particularly when there is strong medical documentation.
Level 4: Medicare Appeals Council
If the ALJ rules against you, you can appeal to the Medicare Appeals Council, which is part of the Department of Health and Human Services. You must request this review within 60 days of the ALJ's decision. The Council reviews the written record from your case and issues a decision.
Level 5: Federal District Court
If the Medicare Appeals Council denies your appeal and the amount in dispute meets a minimum threshold (currently over $1,760, adjusted annually), you can file a lawsuit in Federal District Court. This is the final level of appeal and is typically only necessary for high-value disputes. Most people resolve their appeals at Level 1 or Level 2.
Key Tips to Strengthen Any Appeal
- Your doctor's letter is the most important document. Ask your doctor to be specific about your diagnosis, your functional limitations, and why the requested item or service is medically necessary for your condition.
- Use the word "appeal" in all written communication. Plans are required to process formal appeals differently from general complaints. Using the word "appeal" triggers the formal process with legal timelines.
- Meet every deadline. Missing a deadline can forfeit your right to appeal at that level. Mark the date on your calendar the day you receive a denial.
- Keep copies of everything. Keep copies of all letters you send, all letters you receive, and all supporting documents. Note the date and the name of every person you speak with by phone.
- Request expedited review when medically urgent. If waiting 60 days could seriously harm your health, request an expedited appeal in writing and explain why your situation is urgent.
Getting Free Help With Your Appeal
You do not have to navigate the appeals process alone. Two resources provide free help to Medicare beneficiaries:
- SHIP (State Health Insurance Assistance Program): Free counseling available in every state. SHIP counselors can help you write your appeal letter and understand your rights. Find your local SHIP at shiphelp.org or by calling 1-800-MEDICARE.
- Medicare Rights Center: A national nonprofit that provides free legal help for Medicare appeals. They can be reached at 800-333-4114.
Both organizations are free, unbiased, and do not sell insurance products.