Medicare (Original + Advantage) denial appeals
Medicare is a federal program with two delivery modes, Original (fee-for-service Part A/B + Part D drug plans) and Advantage (private MA-C plans). Each has its own appeal ladder, and rights are stronger than most beneficiaries realize.
If Medicare (Original + Advantage) denied a claim or service, you can appeal, and the plan must give you its file and the criteria it used. Filing windows by plan type: 120 days from the notice (Original Medicare); 65 days from the notice (Medicare Advantage); 65 days from the notice (Part D). The date printed on your denial notice controls; it can only be later than these floors, never earlier.
Medicare (Original + Advantage) appeals: the rule, the deadline and the next level, by plan type
Original Medicare, Medicare Advantage and Part D each have their own federal ladder. The notice you received says which one you are in.
| Plan type | Rule that governs | File your appeal within | The plan must answer | If the plan says no again |
|---|---|---|---|---|
| Original Medicare (Parts A and B) Fee-for-service Medicare. The Medicare Summary Notice lists the denial. | 42 CFR Part 405, Subpart I. | Redetermination: 120 days from receipt of the initial determination (42 CFR 405.942). Reconsideration by a Qualified Independent Contractor: 180 days from the redetermination (§ 405.962). ALJ hearing: 60 days (§ 405.1002). | The Medicare Administrative Contractor decides a redetermination within 60 days (§ 405.950); the QIC decides within 60 days (§ 405.970). | QIC reconsideration, ALJ hearing (amount-in-controversy threshold), Medicare Appeals Council, federal district court. Fast-track appeals of service terminations go to the Quality Improvement Organization (42 CFR 405.1200 to 405.1206). |
| Medicare Advantage (Part C) A private plan that replaces Original Medicare. The card says Medicare Advantage, HMO, PPO or PFFS. | 42 CFR Part 422, Subpart M (§§ 422.560 to 422.634). Coverage decisions must follow Original Medicare rules (42 CFR 422.101). | 65 calendar days from the date on the denial notice to request the plan's reconsideration (42 CFR 422.582, as amended effective 1 January 2025). | Expedited: 72 hours. Standard pre-service: 30 days (7 days for Part B drugs). Payment: 60 days (42 CFR 422.590). | If the plan does not fully reverse itself it must send the case to the Independent Review Entity on its own (42 CFR 422.592); then an ALJ hearing when the amount in controversy meets the annual threshold, the Medicare Appeals Council and federal court. State external review does not apply. |
| Medicare Part D (drug plan or MA-PD) A stand-alone drug plan or the drug benefit inside a Medicare Advantage plan. | 42 CFR Part 423, Subpart M; exceptions under 42 CFR 423.578. | 65 calendar days from the date on the notice to request a redetermination (42 CFR 423.582, as amended effective 1 January 2025). Formulary, tiering and step-therapy exceptions need the prescriber's supporting statement (§ 423.578). | Redetermination: 7 calendar days standard, 72 hours expedited (42 CFR 423.590). Coverage determinations: 72 hours standard, 24 hours expedited, once the prescriber's statement is received (§§ 423.568, 423.572). | Independent Review Entity reconsideration on your request within 65 days of the redetermination notice (§ 423.600); then ALJ, Council and court. |
What you can demand. Follow the appeal instructions on the Medicare Summary Notice or use form CMS-20027. Your provider can appeal for you; any other representative needs form CMS-1696.
How to open the appeal. Cite 42 CFR 405.942 and the coverage rule that applies (the national or local coverage determination), and attach the treating clinician's statement addressed to each coverage criterion.
What you can demand. The plan may not apply internal criteria that are more restrictive than Medicare's national and local coverage determinations, and must decide medical necessity on your individual circumstances (42 CFR 422.101(b), (c)). You can ask for the case file and the criteria used.
How to open the appeal. Cite 42 CFR 422.582 and 422.101(c): the plan must decide on your individual circumstances under Medicare coverage rules, and must forward an unfavorable reconsideration to the IRE itself.
What you can demand. The exception turns on the prescriber's statement that the formulary alternative would be less effective or would harm you (42 CFR 423.578(b)(5)).
How to open the appeal. Cite 42 CFR 423.578 and 423.582 and attach the prescriber's supporting statement written to the exception standard.
Primary sources for this table
- 42 CFR Part 405, Subpart I, Original Medicare appeals
- Medicare.gov, claims and appeals
- 42 CFR Part 422, Subpart M, Medicare Advantage grievances, organization determinations and appeals
- 42 CFR 422.101, Medicare Advantage coverage rules and medical-necessity decisions
- 42 CFR Part 423, Subpart M, Part D coverage determinations, redeterminations and reconsiderations
- 42 CFR 423.578, Part D exceptions process
Windows are federal floors or the rule as written; the denial notice controls. Reviewed 13 September 2026. General information, not legal advice; Apellica is not a law firm.
Patterns we see on Medicare denials
Original Medicare: 5-level appeal
Redetermination by MAC → reconsideration by QIC → ALJ hearing → Medicare Appeals Council → federal district court. The QIC and ALJ levels reverse a substantial share of denials when properly briefed.
Medicare Advantage: identical 5-level ladder
MA plans must follow the same federal appeal structure as Original Medicare. Plan-level reconsideration → Independent Review Entity (Maximus) → ALJ → Council → federal court.
Part D drug coverage denials
Part D appeals follow a separate but parallel ladder. Tiering exceptions and formulary exceptions are filed before a coverage determination challenge.
5 federal levels. Each has its own deadline; the ALJ and court levels require the amount in controversy to meet the annual threshold CMS publishes.
120 days from the notice for level 1 in Original Medicare (redetermination) or 65 days for Medicare Advantage reconsideration (42 CFR 422.582). Later levels: 180 days for the QIC reconsideration in Original Medicare, then 60 days each.
How we file Medicare appeals
Medicare cases require a CMS-1696 Appointment of Representative form for us to act on your behalf. We provide this at intake.
Denied by Medicare? Let's appeal it.
Two-minute micro intake. We confirm fit and reply within one business day. No card at intake. You only pay if the carrier reverses the denial.
Start Your AppealDisclaimer: information shown is general guidance, not legal advice or a guarantee of outcome. Individual case outcomes depend on documentation, timing, and the specific terms of your plan.