What to Do When Medicare Says No
A denial letter reads like a final decision and is the opening of one. Medicare has five levels of appeal, each considered by a different body, with published deadlines and free help available at every stage. A meaningful share of appeals succeed, and the main reason more do not is that people read the letter as the end of the matter.
- Five levels:: Each is considered by a different body, and the later ones are independent of the first decision-maker.
- Deadlines at every stage:: Missing one generally ends the appeal, so the date on the notice is the first thing to read.
- An expedited route:: Where care is about to stop, a fast appeal can be requested and decided quickly.
- Free help exists:: State health insurance assistance programmes help with appeals at no cost.
Where the AI summary above gets this wrong
"If Medicare denies a claim, you have to pay it yourself."
That's surface-true. Here's what it misses:
- The first decision is frequently wrong in a fixable way — Many denials turn on a coding error, a missing document, or a service that was covered but not documented as such. Those are corrected at the first level with a letter and the right paperwork, without anybody arguing about medical necessity at all.
- Care being stopped has its own faster process — Where a hospital, skilled nursing facility or home health agency is ending care, a notice must be given and an expedited appeal can be requested, decided quickly enough to matter. Coverage frequently continues while that review happens, which is the whole point of the fast track.
- Help is free and most people do not use it — Every state has a health insurance assistance programme staffed to help with exactly this, at no cost. Between that, the hospital's own patient advocate and the plan's member services, there is more support available than the letter suggests.
01 The five levels
The first level is a redetermination by the body that made the original decision. The second is a reconsideration by an independent contractor. The third is a hearing before an administrative law judge, the fourth a review by a departmental appeals board, and the fifth judicial review in federal court.
Most appeals are resolved at the first or second level, which is where documentation problems are corrected. The later levels involve a genuine dispute about coverage and are worth pursuing where the amount justifies it.
The route differs slightly depending on whether the coverage is under Original Medicare, an Advantage plan or a Part D plan. Which one applies is stated on the notice, and it matters because the deadlines and the bodies differ — a distinction the choice between coverage routes carries with it.
Shows: the denied amount weighted by the chance you give the appeal, and what that works out at per hour of effort. Ignores: that appeal success rates vary enormously by type and level, the free help available, and the deadlines that end the option entirely.
Source: Claims and appeals
02 Deadlines and the fast track
Each level has a filing deadline running from the date of the notice, and missing one generally ends the appeal regardless of its merits. The date is the first thing to write down.
Where care is about to be discontinued — a hospital discharge, the end of a skilled nursing stay, or home health services stopping — a written notice must be given in advance and an expedited appeal can be requested. Those are decided in days rather than months, and coverage frequently continues while the review takes place.
For a Part D drug denial, a coverage determination can be requested before the drug is even dispensed, along with an exception where a prescriber supports it. That is the route to use when a plan's drug list does not cover a medicine that is clinically necessary — the same list that decides what a year of prescriptions costs under the premium you are already paying.
Source: How do I file an appeal
03 Making an appeal work
The document that matters most is a statement from the treating clinician explaining why the service was medically necessary, referring to the criteria the denial cited. A letter from the patient rarely changes an outcome; a letter from the physician frequently does.
Keep the appeal factual and attach the evidence: the notice, the clinical records, the prescriber's statement, and a short covering letter identifying the claim and what is being asked for. Send it to the address on the notice and keep proof of posting.
Ask for help early rather than late. State health insurance assistance programmes do this daily and know which arguments succeed, and a hospital's patient advocate can obtain the clinical documentation faster than a patient can. Both are free, and using them is the single thing that most improves the odds — alongside simply understanding what the coverage actually promised before the dispute began.
Source: Your Medicare rights
The thing that changes outcomes here is not persistence, though that helps. It is getting one paragraph from the treating doctor explaining why the care was necessary in the terms the denial used. Patients write long, heartfelt letters that do not move anything; a clinician's note addressing the stated criterion frequently does. Ask for that first, and ring the state assistance programme the same day — they do this every week and it costs nothing.
FAQ
Can I appeal a Medicare denial?
Yes. There are five levels of appeal, beginning with a redetermination and progressing to independent review, an administrative law judge, a departmental appeals board and federal court.
What if my care is being stopped?
An expedited appeal can be requested when a hospital, skilled nursing facility or home health agency is ending care. These are decided quickly and coverage frequently continues while the review happens.
Where can I get help with an appeal?
Every state has a health insurance assistance programme that helps at no cost. A hospital's patient advocate and the plan's member services are also worth using.
Sources
Regulator references
- Claims and appeals · Centers for Medicare & Medicaid Services · 2026The appeal levels and what each one considers.Last verified: 2026-09-07
- How do I file an appeal · Centers for Medicare & Medicaid Services · 2026The process and deadlines for each coverage route.Last verified: 2026-09-07
- Your Medicare rights · Centers for Medicare & Medicaid Services · 2026The rights that underlie an appeal, including notice before care ends.Last verified: 2026-09-07
Calculator unit tests · the assertions this page's worked example is checked against, and their last result
Changelog
- 2026-09-07 — initial publish (new format)
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Jordan Reeves
Founder of Talk Through Wealth. A software engineer for over a decade before turning to retirement planning, Jordan built the projection engine after watching family members get fragmented, country-by-country advice that never reconciled. He writes about retirement the way the engine computes it: month-by-month, lifetime-long, and skeptical of any rule of thumb that hasn't been run through the math.