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.
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 and a minimum dollar threshold for the higher levels (ALJ requires $190+ in 2026).
120 days from denial for level 1 (Original) or 60 days for Medicare Advantage. Each subsequent level: 60 days.
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.
Got a Medicare denial?
Free 24-hour review, no obligation. Send the denial letter and we'll tell you within a day whether the case has a shot and what the path would look like.
Send my Medicare denialDisclaimer: 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.