Why Claims Get Denied
Medicare denials happen for a variety of reasons, some administrative and some clinical:
- Medical necessity: Medicare determines the service is not medically necessary for your condition.
- Coverage exclusions: The service is not covered under your plan (e.g., most routine dental work under Original Medicare).
- Coding errors: The provider submitted incorrect billing codes or incomplete documentation.
- Prior authorization: For Medicare Advantage plans, the required pre-approval was not obtained.
- Timeliness: The claim was filed after the deadline.
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The Five Levels of Appeal
Medicare provides up to five levels of appeal. Most beneficiaries only need the first one or two levels to resolve a denial:
- Redetermination — File with the Medicare Administrative Contractor (MAC) for Original Medicare, or with your Medicare Advantage plan. Deadline: 120 days from the date on the Medicare Summary Notice (MSN). Decision within 60 days.
- Reconsideration — If the redetermination upholds the denial, request a review by a Qualified Independent Contractor (QIC). Deadline: 180 days from the redetermination decision.
- Administrative Law Judge (ALJ) Hearing — If the amount in controversy meets the threshold (adjusted annually), you can request a hearing before an ALJ. This level often has the highest overturn rate.
- Medicare Appeals Council Review — A further review if the ALJ decision is unfavorable.
- Federal District Court — A final judicial review for claims meeting a higher dollar threshold.
How to File an Appeal
For Level 1 (the most common), follow these steps:
- Review your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) carefully. It explains why the claim was denied and how to appeal.
- Write a clear appeal letter stating why you believe the service should be covered. Include your name, Medicare number, the denied claim details, and the specific reason you disagree with the denial.
- Ask your doctor to provide a letter of medical necessity explaining why the service is required for your condition.
- Attach all supporting documentation — medical records, test results, physician notes.
- Submit the appeal within the deadline stated on the MSN.
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Getting Help
You do not have to navigate the appeals process alone:
- State Health Insurance Assistance Program (SHIP): Free, unbiased counseling available in every state. Find yours at SHIPhelp.org.
- Your doctor's billing office: They may file the appeal on your behalf or correct coding errors.
- 1-800-MEDICARE (1-800-633-4227): Can help clarify appeal procedures and deadlines.
Key Takeaways
- A denial is a starting point, not a final answer. You have the right to appeal every denial.
- Deadlines matter — note them carefully from your MSN or EOB.
- A letter of medical necessity from your doctor is often the strongest piece of supporting evidence.
- SHIP counselors offer free help with appeals — take advantage of this resource.
