Why Medicare Claims Get Denied
Medicare denies a significant percentage of claims each year — estimates suggest between 10-20% of initial claims receive some form of denial. Common reasons include:
- Not medically necessary — Medicare does not agree the service was required
- Coding errors — incorrect procedure or diagnosis codes on the claim
- Prior authorization missing — particularly common in Medicare Advantage plans
- Service not covered — the procedure is excluded from Medicare benefits
- Provider not enrolled — the doctor or facility is not a Medicare-participating provider
- Frequency limits exceeded — too many of the same service in a time period
The good news: the appeals process is well-defined, and beneficiaries who appeal win a substantial percentage of the time. Studies show that roughly 75-80% of appeals that reach an Administrative Law Judge result in a favorable decision.
The 5 Levels of Medicare Appeals
Level 1: Redetermination
File with the Medicare Administrative Contractor (MAC) that processed the original claim. You have 120 days from the date on your Medicare Summary Notice (MSN). The MAC reviews the claim with different staff than those who made the initial decision. This is the fastest level — decisions typically come within 60 days.
Level 2: Reconsideration
If the redetermination upholds the denial, request reconsideration by a Qualified Independent Contractor (QIC) within 180 days. The QIC is independent of Medicare and provides a fresh review. Decision within 60 days. At this level, submit additional medical records, doctor letters, and clinical evidence.
Level 3: Administrative Law Judge (ALJ)
If the amount in controversy meets the minimum threshold ($190 in 2026), you can request a hearing before an ALJ at the Office of Medicare Hearings and Appeals. This is where your chances improve dramatically. You can present your case in person or by phone, and your doctor can testify. Decisions within 90 days.
Level 4: Medicare Appeals Council
If the ALJ rules against you, appeal to the Medicare Appeals Council (also called the Departmental Appeals Board) within 60 days. The Council can affirm, reverse, or remand the case. Decisions within 90 days.
Level 5: Federal District Court
The final level: judicial review in federal court if the amount in controversy exceeds $1,900 in 2026. File within 60 days of the Appeals Council decision. This is rare but available for high-value claims.
Tips for a Successful Appeal
- Get your doctor involved — A letter of medical necessity from your treating physician is the single most powerful piece of evidence
- Cite Medicare coverage rules — Reference the specific National Coverage Determination (NCD) or Local Coverage Determination (LCD) that supports your claim
- Include medical records — Lab results, imaging, clinical notes showing why the service was needed
- Meet every deadline — Missing a filing deadline can forfeit your appeal rights entirely
- Keep copies of everything — Document every submission with dates and tracking numbers
Medicare Advantage Appeals: Different Rules
If you have a Medicare Advantage plan, the first two levels of appeal go through the plan itself (not a MAC). The plan must make decisions within specific timeframes — 30 days for standard requests, 72 hours for expedited requests. If the plan denies your appeal, an independent review entity conducts the reconsideration. After that, the process follows the same ALJ and higher-level tracks.
Under 2026 rules, MA plans face tighter prior authorization requirements. If your plan denies a service that requires prior auth, you can request an expedited appeal if delay would jeopardize your health. The plan must respond within 72 hours.
Free Help Is Available
You do not have to navigate the appeals process alone. State Health Insurance Assistance Programs (SHIP) provide free, unbiased counseling in every state. SHIP counselors can help you understand your denial, prepare your appeal, and even represent you at an ALJ hearing. Find your local SHIP at your state page or call 1-800-MEDICARE.