Appeal basics

Introduction to appeals

An appeal is a formal request for review of a decision made by Original Medicare or your Medicare Advantage or Part D plan. If you were denied coverage for a health service or item, you may appeal the decision.

Before you start your appeal, make sure you fully read all the letters and notices sent by Medicare and/or your plan. Call 1-800-MEDICARE or your private health or drug plan to learn why your coverage is being denied, if the information was not provided. Your appeal letter should address the reason(s) for denial stated by Medicare or your plan. You can strengthen your appeal by including a letter from your doctor in support of your appeal.

There is more than one level of appeal, and you have the right to continue appealing if you are not successful at the first level. Be aware that at each level there is a separate timeframe for when you must file the appeal and when you will receive a decision. Make sure to file each appeal in a timely manner. If there is a reason you cannot submit your appeal within the timeframe, see whether you are eligible for a good cause extension. Otherwise, your appeal may not be considered.

Keep in mind that an appeal is different from a grievance. A grievance is a formal complaint that you file with your plan.

Use the links below to learn more about different kinds of appeal.

  1. Original Medicare appeals – This section includes information about how to appeal a denial of coverage by Original Medicare.
  2. Medicare Advantage appeals – This section includes information about how to appeal a denial of coverage by your Medicare Advantage Plan. Keep in mind that the process differs depending on whether you are filing a pre-service appeal (you have not yet received your service) or post-service appeal (you have already received your service).
  3. Part D appeals – This section includes information about how to appeal a denial of coverage by your prescription drug plan. You follow the same process regardless of whether you have a stand-alone Part D plan or a Medicare Advantage Plan that includes your prescription drug coverage.
  4. Premium appeals – This section includes information about how to appeal an Income-Related Monthly Adjustment Amount (IRMAA) determination (meaning you pay a higher Part B or Part D premium).

If you have additional questions about the appeal process, there are resources to help you understand your rights.