How to appeal a Medicare denial (82% win at level 1)

A denial letter from Medicare looks final. It is not. Medicare appeals are won at rates that surprise most families — often higher than 80% at the first level — when filed correctly and on time. The appeal costs you nothing. Most denials never get appealed because families don't know they can.

This is the playbook for getting your parent's care covered when Medicare or a Medicare Advantage plan says no.

What gets denied

The most common Medicare denials hit one of these:

• Skilled nursing facility (SNF) coverage extension past Day 20 or beyond
• Home health visits beyond initial certification
• Inpatient rehabilitation facility (IRF) admission or extension
• Durable medical equipment (DME) — wheelchairs, hospital beds, oxygen
• Specific medications (especially in Part D plans)
• Inpatient admission converted retroactively to observation
• Medicare Advantage prior authorization denials for any of the above

The denial usually arrives as a letter — sometimes called an "Adverse Benefit Determination" or "Notice of Medicare Non-Coverage". Read it carefully. It will state:

• What service is being denied
• The specific reason for denial
• The effective date
• The deadline to file an appeal

That deadline is the most important date on the page. Miss it and most appeal routes close.

Original Medicare vs Medicare Advantage

The appeal process differs depending on which type of Medicare coverage your parent has.

Original Medicare(Parts A & B): appeals go through a 5-level process managed by Medicare itself.

Medicare Advantage (Part C): appeals start with the plan itself, then escalate to an independent review entity, then to ALJ hearings. Different timelines, different forms.

Part D (prescriptions): similar to Medicare Advantage — starts with the plan, then external review.

Medicare Advantage denial rates have roughly doubled since 2020 according to multiple federal audits. That's the most important structural change in Medicare in the last decade. If your parent is on Medicare Advantage and got denied, the appeal is even more worth your time than under Original Medicare.

Hospital discharge appeals (the most urgent)

A special appeal route exists when a hospital tells you your parent will be discharged and you believe it's too soon. This is the QIO appeal.

How it works:

1. The hospital must give you an "Important Message from Medicare" form within 2 days of admission and again before discharge
2. The form lists the local Quality Improvement Organization (QIO) phone number
3. You call the QIO before discharge happens
4. The QIO reviews the case (usually within 24 hours)
5. The hospital cannot discharge while the appeal is pending
6. If you win the appeal, Medicare pays for continued stay
7. If you lose, you have until noon the next day to discharge

Cost to you: $0. Medicare pays the QIO. Filing an appeal does not damage your relationship with the hospital despite what some staff may imply.

SNF discharge appeals (also urgent)

If your parent is in a SNF and gets a Notice of Medicare Non-Coverage (NOMNC) telling them coverage ends in 2 days, you have the same urgent QIO appeal right. Same playbook — call the QIO immediately, before the cutoff.

SNF discharges are appealed less often than they should be. Many families assume "Medicare decided" means "Medicare decided." In reality, "not improving" is interpreted aggressively by Medicare contractors, and many patients are still benefiting from skilled care when the cut-off comes. Appeal first, discharge second.

Standard appeals (less urgent, longer process)

For denials of services already received, prior authorization for upcoming services, or DME/medication denials — you have a longer appeal window but more procedural steps.

Original Medicare — the 5 levels

1. Level 1: Redetermination by the Medicare Administrative Contractor (MAC). Decision within 60 days. Most cases resolve here.
2. Level 2: Reconsideration by a Qualified Independent Contractor (QIC). Decision within 60 days.
3. Level 3: Administrative Law Judge (ALJ) hearing. Minimum $190 amount-in-controversy threshold. Decision within 90 days (though often longer).
4. Level 4: Medicare Appeals Council review.
5. Level 5: Federal District Court. Minimum $1,900 amount-in-controversy threshold.

Medicare Advantage — the 4-stage process

1. Stage 1: Plan reconsideration. The MA plan reviews its own denial. Decision within 30 days (standard) or 72 hours (expedited).
2. Stage 2: Independent Review Entity (IRE). Outside review. Decision within 30 days (or 72 hours expedited).
3. Stage 3: ALJ hearing. Same threshold as Original Medicare.
4. Stage 4: Council and federal court. Same final stages.

Most appeals are won at Stage 1 or 2. The data from CMS and HHS Office of Inspector General audits consistently show high win rates at early levels when appeals are filed.

How to file the appeal

Step 1: Get the denial letter and read it carefully

The letter tells you the exact deadline and the exact form to use. Note the date on the letter — your appeal window typically starts from the date of receipt (or the date listed on the letter).

Step 2: Get your parent's medical records

You have the right to request records under HIPAA. Submit a HIPAA release form to the relevant providers. You'll want:

• The complete relevant chart notes
• Physician notes documenting medical necessity
• Therapy notes (for SNF/home health appeals — PT, OT, speech)
• Test results, imaging, and labs that support the case
• The discharge summary (for hospital-related appeals)

Step 3: Get a letter of medical necessity from the treating physician

This is the single highest-leverage item in most appeals. Ask the treating physician to write a letter stating:

• The diagnosis
• The specific medical need for the denied service
• Why that specific service is medically necessary
• What harm would result from not providing it
• Reference to relevant Medicare coverage rules (the physician's office or hospital billing department can help with this)

Most physicians will write this. They may charge a modest fee. It's worth it. A clear physician letter doubles to triples the win rate on appeals in most case studies.

Step 4: Fill out the appeal form

The form is on the back of the denial letter, or is referenced. For Original Medicare, the standard form is CMS-20027 (Medicare Redetermination Request). For Medicare Advantage, the form is provided by the plan.

Fill out:

• Patient information
• The service being appealed
• The date of the original denial
• Reason for appeal (in plain English, with specific reference to medical necessity and any rule the denial may have misapplied)
• Attach the medical necessity letter, supporting medical records, and any additional documentation

Step 5: File on time, by the right method

File the appeal by the deadline on the denial letter. Most appeals can be filed by mail, fax, or in some cases online or by phone. Use a method with proof of receipt — certified mail, fax with confirmation, or online portal screenshot.

Keep copies of everything. If the case escalates to a higher level, you'll need them.

Step 6: Track the deadline

The reviewer has a deadline to respond (typically 60 days for Original Medicare Level 1, 30 days for Medicare Advantage). If they miss the deadline, you can escalate to the next level by default.

Expedited (fast) appeals

If waiting the standard timeline would seriously jeopardize your parent's health, you can request an expedited appeal:

• Original Medicare: 72 hours for expedited redetermination
• Medicare Advantage: 72 hours for expedited plan reconsideration; 72 hours for expedited IRE review
• Part D: 24 hours for expedited determination on critical medications

The criteria: there must be substantial risk of harm to life, health, or recovery from waiting. The treating physician's support letter should explicitly state this when relevant.

Common mistakes

1. Missing the deadline. The clock starts when the denial letter is dated or received. Don't let it lapse.
2. Filing the wrong form. Original Medicare and Medicare Advantage have different forms. Read the letter carefully.
3. Skipping the physician letter. This is the single highest-leverage item.
4. Not requesting medical records. Records back up the physician's letter and let the reviewer see the full picture.
5. Giving up after Level 1. Many appeals that lose at Level 1 win at Level 2. The independent review at Stage/Level 2 is often where the denial gets overturned.
6. Not requesting expedited review when the situation warrants it.

When to get help

For most denials, you can do the appeal yourself. Free resources exist:

• State Health Insurance Assistance Program (SHIP): free, unbiased Medicare counseling by trained volunteers. Find yours at shiphelp.org.
• Medicare Rights Center: free consumer help. 1-800-333-4114.
• Center for Medicare Advocacy: nonprofit advocacy. Free educational materials and self-help guides.
• The QIO directly: for hospital and SNF discharge appeals.

For complex or high-dollar denials (especially anything heading to ALJ hearings or above), consider:

• Patient advocates. Hourly rates from $75 to $250. Some specialize in Medicare appeals.
• Healthcare attorneys. Hourly $200–500. Often unnecessary at Level 1–2 but useful at ALJ and above.

Bottom line

The denial letter is not the final word. A meaningful percentage of denials are reversed on appeal — often 80%+ at the first level — when appeals are filed with a clear physician letter, supporting records, and on time.

The hospital staff or insurance representative who handed you the denial may discourage appeals or imply they're unlikely to succeed. They are wrong, or they have reasons not to share. The appeal route exists because Medicare law requires it. Use it.

Read the denial letter today. Note the deadline. Request the records. Get the physician letter. File before the deadline. That sequence wins a lot of money back for a lot of families.