What happens when Medicare says no

When Medicare denies a claim for a service, test, or piece of equipment, you have the right to challenge that decision. The appeal process has five levels, and most denials can be overturned at the first or second level if you send the right paperwork. You do not need a lawyer, though you can hire one if you choose. The key is understanding which level applies to your situation and what documents Medicare needs to reconsider.

Medicare sends you a notice called an Explanation of Benefits (EOB) or Medicare Summary Notice (MSN) when it denies a claim. This notice tells you why the claim was denied — usually because Medicare decided the service was not medically necessary, was not covered, or was billed incorrectly. The notice also tells you how long you have to appeal and which level to start at.

Key Takeaways

  • You have 120 days from the date on your denial notice to file an appeal at Level 1, which is called a redetermination.
  • Level 1 appeals go back to the same Medicare contractor that made the original denial, so include new medical evidence or a letter from your doctor explaining why the service was medically necessary.
  • If Medicare denies your Level 1 appeal, you can move to Level 2 (reconsideration) within 180 days, which sends your case to a different contractor for a fresh review.
  • Levels 3, 4, and 5 involve independent reviewers and judges, but most cases are resolved by Level 2 if you provide strong medical documentation.
  • You can ask your doctor, a patient advocate, or a Medicare counselor to help you gather evidence and write your appeal letter.

Level 1: Redetermination by the same contractor

A redetermination is your first appeal. You send it to the Medicare contractor that made the original denial — the same organization that processed your claim the first time. You have 120 days from the date printed on your denial notice to file.

To file a Level 1 appeal, send a written request to the address listed on your denial notice. Include your name, Medicare number, the date of service, and a clear statement that you disagree with the denial. Explain why you believe the service was medically necessary. If your doctor has not yet provided a statement, ask them to write one saying the service was appropriate for your condition. This new medical evidence is often what changes the outcome.

Mail your appeal or ask your provider to mail it on your behalf. Keep a copy for your records. Medicare has 60 days to review and respond. If they uphold the denial, they will send you another notice explaining why and telling you how to move to Level 2.

Level 2: Reconsideration by a different contractor

If Medicare denies your Level 1 appeal, you can request a reconsideration. This sends your case to a different Medicare contractor — not the one that made the original decision. You have 180 days from the date of your Level 1 denial notice to file.

A reconsideration is worth pursuing because a fresh set of eyes reviews your case. Send the same information you sent for Level 1, plus any additional medical records or doctor's letters you have gathered since then. If your doctor has new information about your condition or why the service was necessary, include that. The second contractor has 60 days to decide.

Most successful appeals end at Level 2. If this contractor also denies your appeal, you can move to Level 3, but that involves an independent reviewer outside Medicare and takes longer.

Levels 3, 4, and 5: Independent review and appeals council

If Medicare denies your Level 2 appeal, you can request a hearing before an administrative law judge (Level 3). This requires that the amount in dispute meets a minimum dollar threshold, which varies by year. You have 60 days from your Level 2 denial to request this hearing.

At Level 3, an independent judge who does not work for Medicare reviews your case. You can present new evidence and, if you wish, appear by phone or video. The judge has 90 days to decide. If you disagree with that decision, you can appeal to the Medicare Appeals Council (Level 4) within 60 days, and then to federal court (Level 5) if needed. Very few cases reach these levels.

What to include in your appeal letter

Your appeal letter should be clear and specific. Start by stating which claim you are appealing — include the date of service, the type of service (for example, "physical therapy on March 15, 2024"), and the amount billed. Then explain why you believe Medicare's decision was wrong.

If Medicare said the service was not medically necessary, ask your doctor to explain in writing why it was. If Medicare said it was not covered, include the policy or rule that you believe shows it should be covered. If there was a billing error, provide the correct information. Attach copies of relevant medical records — test results, progress notes, or imaging reports that support your case. Do not send originals; Medicare will not return them.

Keep your letter to one or two pages. Be factual and avoid emotional language. Medicare reviewers respond to medical evidence, not to how upset you are about the denial.

Getting help with your appeal

You do not have to handle this alone. Your doctor's office can often help gather medical records and write a supporting letter. Many doctors' billing staff are familiar with appeals and can advise you on what Medicare is likely to accept.

If you need more support, contact your State Health Insurance information Program (SHIP). SHIP offers free counseling about Medicare appeals. You can find your local SHIP by calling 1-800-MEDICARE or visiting the Medicare website. A SHIP counselor can review your denial notice, help you understand why Medicare said no, and guide you through the appeal process.

Some people hire a Medicare advocate or attorney, especially if the amount in dispute is large or the case is complex. You can find advocates through your state's aging agency or through patient organizations related to your condition. If you hire an attorney, they typically work on contingency — meaning they take a percentage of what they recover for you, not an upfront fee.

Timeline and what to expect

The appeal process can take several months. At Level 1, expect a decision within 60 days. At Level 2, another 60 days. If you move to Level 3 (administrative law judge), the timeline stretches to 90 days or longer, depending on how busy the judge's office is.

While you are waiting, you are not required to pay the bill. Medicare holds the provider's payment during the appeal. If you win, Medicare pays the provider and you owe nothing. If you lose, the provider may bill you, but you can ask for a payment plan if you cannot pay in full.

Keep copies of everything you send — your appeal letter, medical records, doctor's statement, and the date you mailed it. If Medicare says they never received your appeal, you will have proof that you sent it.

Frequently Asked Questions

Can I appeal if my doctor says the service was not medically necessary?

Yes. If your doctor now believes the service was necessary, ask them to write a new statement explaining why. If your doctor still agrees with Medicare's denial, you may not have a strong case, but you can still file an appeal and present other evidence — such as clinical guidelines or peer-reviewed studies — that support the service.

Do I have to pay the bill while I am appealing?

No. Medicare holds the payment to the provider while your appeal is pending. You should not receive a bill during the appeal process. If you do, contact the provider and tell them you have filed an appeal.

What if I miss the 120-day important date for Level 1?

You may still be able to appeal, but you will need a good reason for the delay — such as a serious illness or mail delivery problems. Contact the Medicare contractor listed on your denial notice and explain why you missed the important date. They can decide whether to accept a late appeal.

Can I appeal more than once for the same service?

You can appeal through all five levels if you choose, but you cannot file multiple appeals at the same level. Once Medicare denies your Level 1 appeal, you move to Level 2. You cannot file another Level 1 appeal for the same claim.

What if Medicare approves my appeal but only pays part of the bill?

If Medicare approves the service but pays less than the provider billed, the provider may bill you for the difference. You can ask the provider to write off the balance, or you can appeal the payment amount separately if you believe it is incorrect.