Getting denied doesn't mean it's over. Medicare and Medicaid denials are overturned more often than you'd think — IF you know how to fight back. This guide shows you exactly how.
Every Medicare and Medicaid denial comes with appeal rights. The government is required to tell you why you were denied and how to challenge it. But here's what they don't tell you: appeals work.
Studies consistently show that a significant percentage of Medicare denials are overturned on appeal — especially at the early levels. A 2022 HHS Office of Inspector General report found that many Medicare Advantage prior authorization denials were for services that actually should have been approved.
The system counts on you giving up. Don't.
In my 20+ years at SSA, I saw countless people accept denials they shouldn't have. The bureaucracy makes it feel hopeless — that's by design. But the appeals process exists because the system makes mistakes. Wrong information, misapplied rules, incomplete files. If you believe you should have been approved, appeal every time.
Level 1: Redetermination — Request a review from your plan (MA) or Medicare contractor (Original Medicare) within 60 days of the denial. This is a paper review — no hearing needed. Decision due within 60 days.
Level 2: Reconsideration — If Level 1 upholds the denial, request reconsideration from a Qualified Independent Contractor (QIC) within 180 days. An independent reviewer looks at the case fresh.
Level 3: ALJ Hearing — Request a hearing before an Administrative Law Judge if the amount in dispute is at least $190 (2026). You can present your case by phone, video, or in person. This is where many denials get overturned.
Level 4: Medicare Appeals Council — Review by the Departmental Appeals Board if still denied at Level 3.
Level 5: Federal Court — Judicial review in federal district court if the amount in dispute is at least $1,900 (2026). Rarely needed.
Important: At every level, submit your appeal on time. Missing a deadline can forfeit your appeal rights.
Most people never get past Level 1. But Level 2 and especially Level 3 (the ALJ hearing) is where the magic happens. An independent judge reviews your case with fresh eyes. Bring documentation: your doctor's letters, medical records, and a clear explanation of why the service is medically necessary. SHIP counselors can help you prepare — and it's free.
Medicaid appeals work differently because Medicaid is run by your state. But you still have strong rights:
Notice of Action: Your state must send you a written notice explaining the denial and your appeal rights.
Fair Hearing: You have the right to request a fair hearing (usually within 30–90 days of the denial, depending on your state). This is an independent review.
Aid Pending: If you're currently receiving Medicaid and they're reducing or terminating your benefits, you can request that benefits continue during the appeal ("aid pending"). You must request this quickly — typically within 10 days of the notice.
Free legal help: Contact your state's Legal Aid office or the Medicare Rights Center (800-333-4114) for free assistance with Medicaid appeals.
1. Read the denial letter carefully. It tells you exactly why you were denied. Your appeal needs to address that specific reason.
2. Get your doctor involved. A letter of medical necessity from your doctor is the most powerful tool in a Medicare appeal. Ask your doctor to explain why the service is medically necessary for YOUR specific situation.
3. Document everything. Keep copies of all correspondence, medical records, and appeal submissions. Create a timeline of events.
4. Meet every deadline. Appeals have strict time limits. Miss one and you may lose your right to appeal at that level.
5. Get free help. SHIP counselors, Legal Aid, and the Medicare Rights Center can all help you prepare and file appeals at no cost.
6. Don't give up after Level 1. The first level is often a rubber stamp. Level 2 (independent review) and Level 3 (ALJ hearing) have much higher overturn rates.
Downloadable templates for Medicare and Medicaid appeal letters — with fill-in-the-blank sections and a medical necessity guide.
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SHIP (State Health Insurance Assistance Program): Free Medicare counseling. Call 877-839-2675 or visit shiphelp.org.
Medicare Rights Center: Free helpline at 800-333-4114. National nonprofit that helps with Medicare appeals and coverage questions.
Legal Aid: Find your local Legal Aid office at lawhelp.org. Free legal assistance for low-income individuals with benefit denials.
Beneficiary & Family Centered Care – Quality Improvement Organizations (BFCC-QIO): Independent organizations that review quality of care complaints and Medicare appeals. Find yours at qioprogram.org.
Your State Medicaid Office: For Medicaid-specific appeals. Find yours at medicaid.gov/state-overviews.