Your plan must send a written notice explaining why it denied the service or drug and how long you have to appeal.
For Medicare Advantage or Part D, you now get 65 days from the date on the notice (up from 60).
Billing code swapped? Wrong provider ID? A simple correction from your doctor’s office can flip a denial into an approval without a formal appeal.
Ask your doctor for progress notes, test results, and a brief letter stating why the service or drug is essential. Strong documentation wins most first-level appeals.
Original Medicare: file a “redetermination” with the Medicare contractor.
Medicare Advantage / Part D: file a “reconsideration” with your plan (use its form or submit a letter).
Urgent cases—where delaying care risks your health—qualify for an expedited review: plans must respond within 72 hours; standard cases within 7 days starting in 2026.
If Level 1 fails, keep climbing:
Independent Review Entity (Maximus)
Office of Medicare Hearings & Appeals (ALJ)
Medicare Appeals Council
Federal court (if the amount at stake is high enough) Each decision letter tells you exactly how and when to move to the next stage.
Keep a denial-and-appeal folder: notices, medical records, dates, names, and confirmation numbers. Send appeal packets by certified mail or secure upload so you have proof of receipt.
State Health Insurance Assistance Program (SHIP). Free, unbiased help with Medicare appeals.
Physician “peer-to-peer” call. Your doctor can speak directly with the plan’s medical director.
Plan shopping window. If your Medicare Advantage plan over-denies, you can switch during the Jan 1–Mar 31 Open Enrollment Period.
Key stat: Only about 10 % of Medicare Advantage denials are appealed, yet 83 % of those appeals succeed. Don’t leave money—or care—on the table.
Our licensed Medicare advocates can decode your denial and draft an appeal checklist—free of charge. Call 888-376-2028 today.
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