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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Virgil Insurance Agency, LLC (DBA Fair Square Medicare) and www.fairsquaremedicare.com are privately owned and operated by Help Button Inc. Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. This is a solicitation of insurance. A licensed agent/producer may contact you. Medicare Supplement insurance is available to those age 65 and older enrolled in Medicare Parts A and B and, in some states, to those under age 65 eligible for Medicare due to disability or End-Stage Renal disease. Virgil Insurance Agency is a licensed and certified representative of Medicare Advantage HMO, HMO SNP, PPO, PPO SNP and PFFS organizations and stand-alone PDP prescription drug plans. Each of the organizations we represent has a Medicare contract. Enrollment in any plan depends on contract renewal. The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. Plan availability varies by region and state. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov. © 2025 Help Button Inc
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