Denied Coverage? What to Do When Your Carrier Says No

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Denied Coverage? What to Do When Your Carrier Says No

By Daniel Petkevich

Jul 15, 2025

An overview of what to do when you're denied coverage by carrier for Medicare.

1 Confirm the Denial and the Deadline

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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).

2 Look for Fix-It-Fast Errors

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.

3 Gather “Medical Necessity” Ammo

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.

4 File Your Level 1 Appeal Promptly

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.

5 Escalate If Needed

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.

6 Track Everything

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.

7 Know Your Backup Options

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.

Need a Hand?

Our licensed Medicare advocates can decode your denial and draft an appeal checklist—free of charge. Call 888-376-2028 today.

Speak with a Medicare Advocate

Talk to one of our Licensed Medicare Agents today to find the right plans for you.

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Denied Coverage? What to Do When Your Carrier Says No

An overview of what to do when you're denied coverage by carrier for Medicare.

1 Confirm the Denial and the Deadline

Speak with a Medicare Advocate

2 Look for Fix-It-Fast Errors

3 Gather “Medical Necessity” Ammo

4 File Your Level 1 Appeal Promptly

5 Escalate If Needed

6 Track Everything

7 Know Your Backup Options

Need a Hand?

Speak with a Medicare Advocate

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About

Medicare 101

Current Clients

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