What happens when Medicare says no

When Medicare denies a claim, you receive a document called a Explanation of Benefits (EOB) or Medicare Summary Notice (MSN) that explains why. The denial does not mean you cannot get the service or item — it means Medicare decided not to pay for it at that moment. You have the right to challenge that decision, and the appeal process has specific steps and time limits you need to follow.

The reason for denial matters. Medicare might deny a claim because the service was deemed not medically necessary, the provider billed incorrectly, you have not met your deductible, or the item is not covered under your plan. Understanding which reason applies to you determines what you argue in your appeal.

Key Takeaways

  • You have 120 calendar days from the date on your denial notice to file a Level 1 appeal, which is your first chance to challenge the decision.
  • Your denial notice lists the specific reason Medicare said no — read this carefully because your appeal must address that exact reason.
  • A Level 1 appeal goes back to the same Medicare contractor who made the first decision, and you can submit new medical records or a written statement explaining why you disagree.
  • If Medicare denies your Level 1 appeal, you can move to Level 2 (independent review), Level 3 (hearing), Level 4 (appeals council), and Level 5 (federal court), but most people stop at Level 2 or 3.
  • You do not need a lawyer to appeal, but having one can help if your case involves large amounts of money or complex medical questions.

Finding your denial notice and understanding the reason

Your denial notice arrives in the mail and contains several pieces of information you will need. The document shows the date of the notice (this is when your 120-day clock starts), the service or item that was denied, the amount Medicare would have paid, and most importantly, the reason for the denial written in a box labeled "Why we denied this claim" or similar language.

Common denial reasons include: "Not medically necessary," "Exceeds frequency limits," "Requires prior authorization," "Not a covered service," or "Billed by non-participating provider." Write down the exact reason from your notice. This is what you will address in your appeal. If the reason is unclear, call the phone number on your notice and ask them to explain it in plain language before you file.

Keep the original notice in a safe place. You will reference it throughout the appeal process, and you may need to show it to your doctor or a representative later.

Filing a Level 1 appeal within 120 days

A Level 1 appeal is your first formal challenge. You have 120 calendar days from the date printed on your denial notice to file one. The appeal goes back to the Medicare contractor (the company that processed your original claim), not to a new reviewer.

To file, you can use Form CMS-20027, which is the official appeal request form. You can read it from Medicare.gov, ask your doctor's office to help you fill it out, or call 1-800-MEDICARE to request a paper copy by mail. You do not have to use the form — you can also write a letter stating that you want to appeal and include your claim number, the date of service, and the reason you disagree with the denial.

Send your appeal and any supporting documents to the address listed on your denial notice. Include copies (not originals) of new medical records, test results, or a letter from your doctor explaining why the service was medically necessary. Do not send originals — Medicare may not return them. Mail it certified with return receipt so you have proof it arrived.

Medicare has 60 days to review your Level 1 appeal and send you a decision. If they uphold the denial, you will receive another notice explaining why and telling you how to file a Level 2 appeal.

What to include in your appeal letter or form

Whether you use the official form or write a letter, include these details: your name, Medicare number, the date of service, the specific service or item that was denied, and your claim number (found on your denial notice). Then address the reason for the denial directly.

If Medicare said the service was not medically necessary, explain why it was. Include a statement from your doctor if possible — a short letter saying the service was appropriate for your condition is powerful evidence. If Medicare said you exceeded frequency limits, explain why you needed it more often. If they said it requires prior authorization, explain that you did not know and ask them to reconsider now that you have submitted the authorization request.

Keep your explanation clear and factual. You do not need legal language. A paragraph or two is usually enough. Attach copies of any new medical records, test results, or documentation that supports your case. Number your pages and list what you are sending so Medicare knows nothing is missing.

Level 2 appeal: independent review

If Medicare denies your Level 1 appeal, you can request a Level 2 appeal, which sends your case to an independent reviewer who was not involved in the first decision. You have 180 calendar days from the date of your Level 1 denial notice to file a Level 2 appeal.

Use Form CMS-20033 to request Level 2 review, or write a letter stating you want an independent review. Send it to the address listed on your Level 1 denial notice. The independent reviewer will look at all the evidence you submitted plus any new information you want to add.

Level 2 review usually takes 60 days. If the reviewer agrees with Medicare, you receive another notice. If the amount in question is $200 or more, you can move to a Level 3 appeal (hearing before an administrative law judge). If it is less than $200, Level 2 is usually the end of the road, though you can still pursue it if the principle matters to you.

Level 3 and beyond: when to consider a lawyer

A Level 3 appeal is a hearing before an Administrative Law Judge (ALJ), and it is available only if the amount in question is $200 or more. You have 60 days from your Level 2 denial to request this hearing. At Level 3, you can present new evidence, have your doctor testify (usually by phone), and argue your case directly.

This is where a lawyer becomes useful. An attorney who handles Medicare appeals can prepare your case, gather medical evidence, and represent you at the hearing. Many work on contingency, meaning they take a percentage of any money you win rather than charging you upfront. If you cannot afford a lawyer, ask the ALJ office about legal aid organizations in your area.

If you lose at Level 3, you can appeal to the Medicare Appeals Council (Level 4) and then to federal court (Level 5), but these are rare and usually involve large sums or novel legal questions. Most people either win at an earlier level or decide the cost and time are not worth continuing.

What to ask your doctor and when to seek help

Before you file any appeal, talk to your doctor. Ask them directly: "Why did you order this service, and is it medically necessary for my condition?" Ask them to put the answer in writing — even a brief note in your medical record helps. If they believe Medicare made a mistake, ask if they will write a letter supporting your appeal. Many doctors will do this at no charge because they believe the service was appropriate.

Contact your State Health Insurance information Program (SHIP) if you get stuck. SHIP is a free counseling service funded by Medicare, and counselors can explain your appeal rights, help you understand your denial notice, and guide you through the process. Find your state's SHIP by calling 1-800-MEDICARE or visiting shiptalk.org.

Consider a lawyer if the amount denied is large (over $1,000), the medical question is complex, or you have already lost at Level 2 and want to pursue a hearing. The National Organization of Social Security Claimants' Representatives (NOSSCR) has a directory of attorneys who handle Medicare appeals.

Frequently Asked Questions

Does filing an appeal cost money?

No. Filing a Level 1, 2, or 3 appeal costs nothing. You pay only for copies of medical records if you request them from your doctor or hospital, and that cost is usually under $25. If you hire a lawyer, they typically take 25% of the money you win, not a fee upfront.

What if I miss the 120-day important date for Level 1?

You lose your right to appeal at that level. However, you may be able to ask Medicare to reopen the claim if you have "good cause" — for example, you were hospitalized and did not receive the notice, or Medicare made a factual error. Call 1-800-MEDICARE and explain your situation. They will tell you whether reopening is possible.

Can I appeal while I am still receiving the service?

Yes. You do not have to wait until the service is finished. In fact, appealing early can sometimes stop you from owing money out of pocket. File as soon as you receive the denial notice.

What if my doctor says the service was not medically necessary?

If your own doctor agrees with Medicare's denial, you have a weak case for appeal. Ask your doctor why they think it was not necessary. If you disagree with their assessment, you can seek a second opinion from another doctor and include that in your appeal, but the original doctor's position will work against you.

How long does the whole appeal process take?

A Level 1 appeal takes about 60 days. A Level 2 appeal takes another 60 days. A Level 3 hearing can take several months depending on the judge's schedule. From start to finish, a full appeal can take six months to a year or longer if you go to Level 4 or 5.