Skip to main content
Cancer Explained
Donate

When Medicare says no

A denial is not a final answer. It is the first move in a process you have a legal right to use, and a meaningful share of appeals succeed — particularly when a doctor writes in support. What matters is doing it quickly and doing it in the right system, because there are three of them and they use different words for the same step.

If waiting could harm you, say so — in these words

“I am requesting an expedited review because waiting for a standard decision could seriously jeopardize my life, my health, or my ability to regain maximum function.”

That sentence triggers an expedited review. It turns a decision that could take 30 days into one that must come in 72 hours, and it is a right rather than a favor. Your plan must grant it if any doctor supports the request. Say it on the phone, and put it in writing.

When is your deadline?

Appeals are lost on dates more often than on merits. Tell it which kind of coverage denied you and when the letter arrived.

Your coverage comes from a Medicare Advantage plan — an HMO, PPO, or Special Needs Plan run by an insurance company — and it denied a scan, surgery, hospital stay, or an infused drug.

The date it arrived, not the date printed on it. If you are not sure, Medicare assumes five days after the printed date.

Enter the date the letter arrived to see your deadline.

This is a working estimate to help you plan, not legal advice. Always check the deadline printed on your own denial notice — it governs. If your appeal is urgent, do not wait for the deadline at all: ask for an expedited review, which your plan must decide in 72 hours.

Which system are you in?

This is the part most guides get wrong, and getting it wrong costs days. A Medicare Advantage plan does not do “redeterminations” — ask for one and you will be told no such thing exists. Find your row before you pick up the phone. Last checked against CMS on July 25, 2026.

Medicare Advantage (Part C)

Your coverage comes from a Medicare Advantage plan — an HMO, PPO, or Special Needs Plan run by an insurance company — and it denied a scan, surgery, hospital stay, or an infused drug.

  1. Level 1

    Reconsideration by your plan

    Decided by
    The Medicare Advantage plan that denied it
    You must file within
    60 days from when you received the denial notice
    They must answer within
    30 days for care you have not had yet, 60 days for a bill already incurred, 7 days for a Part B drug — or 72 hours if it is expedited

    It is called a reconsideration, not a redetermination. Asking for the wrong one wastes days.

  2. Level 2

    Reconsideration by the Independent Review Entity

    Decided by
    An independent organization under contract to Medicare
    You must file within
    You do not have to file — the plan must forward it automatically
    They must answer within
    72 hours expedited, 30 days for pre-service care, 60 days for payment

    If your plan upholds its denial it is required to send the case on for you. If nobody contacts you within about a week, call the plan and confirm it was forwarded.

  3. Level 3

    Hearing before an administrative law judge

    Decided by
    The Office of Medicare Hearings and Appeals, part of Health and Human Services
    You must file within
    60 days from the independent reviewer's decision
    They must answer within
    No fixed deadline for Medicare Advantage cases

    The amount in dispute must be at least $200 in 2026.

  4. Level 4

    Medicare Appeals Council review

    Decided by
    The Departmental Appeals Board
    You must file within
    60 days from the judge's decision
    They must answer within
    No fixed deadline for Medicare Advantage cases
  5. Level 5

    Federal district court

    Decided by
    A federal judge
    You must file within
    60 days from the Council's decision
    They must answer within
    No limit

    The amount in dispute must be at least $1,960 in 2026.

CMS guidance for Medicare Advantage (Part C)

Part D prescription drugs

A drug plan refused to cover a prescription, put it on a tier you cannot afford, or is requiring you to try a different drug first.

  1. Before you appeal

    Coverage determination or exception request

    Decided by
    Your drug plan
    You must file within
    Any time — this comes before an appeal exists
    They must answer within
    72 hours standard, 24 hours expedited

    For an exception — a formulary exception to cover a drug that is not on the list, or a tiering exception to move it to a cheaper tier — the clock does not start until your prescriber sends a supporting statement. Ask your oncologist's office to send it the same day.

  2. Level 1

    Redetermination

    Decided by
    Your drug plan
    You must file within
    60 days from the coverage determination
    They must answer within
    7 days standard, 72 hours expedited, 14 days for a payment request
  3. Level 2

    Reconsideration by the Independent Review Entity

    Decided by
    An independent organization under contract to Medicare
    You must file within
    65 days from the date on your plan's redetermination
    They must answer within
    7 days standard, 72 hours expedited

    Unlike Medicare Advantage, you must file this one yourself.

  4. Level 3

    Hearing before an administrative law judge

    Decided by
    The Office of Medicare Hearings and Appeals
    You must file within
    60 days from the independent reviewer's decision
    They must answer within
    90 days, or 10 days if expedited

    The amount in dispute must be at least $200 in 2026.

  5. Level 4

    Medicare Appeals Council review

    Decided by
    The Departmental Appeals Board
    You must file within
    60 days from the judge's decision
    They must answer within
    90 days, or 10 days if expedited
  6. Level 5

    Federal district court

    Decided by
    A federal judge
    You must file within
    60 days from the Council's decision
    They must answer within
    No limit

    The amount in dispute must be at least $1,960 in 2026.

CMS guidance for Part D prescription drugs

Original Medicare (Parts A and B)

You have red-white-and-blue Medicare rather than a plan from an insurance company, and a claim on your Medicare Summary Notice was denied.

  1. Level 1

    Redetermination

    Decided by
    The Medicare Administrative Contractor that processed the claim
    You must file within
    120 days from when you received the Medicare Summary Notice
    They must answer within
    60 days

    You can file by circling the item on your Medicare Summary Notice, writing why you disagree, and mailing it to the address on the notice.

  2. Level 2

    Reconsideration

    Decided by
    A Qualified Independent Contractor
    You must file within
    180 days from the redetermination
    They must answer within
    60 days
  3. Level 3

    Hearing before an administrative law judge

    Decided by
    The Office of Medicare Hearings and Appeals
    You must file within
    60 days from the reconsideration
    They must answer within
    90 days

    The amount in dispute must be at least $200 in 2026.

  4. Level 4

    Medicare Appeals Council review

    Decided by
    The Departmental Appeals Board
    You must file within
    60 days from the judge's decision
    They must answer within
    90 days
  5. Level 5

    Federal district court

    Decided by
    A federal judge
    You must file within
    60 days from the Council's decision
    They must answer within
    No limit

    The amount in dispute must be at least $1,960 in 2026.

CMS guidance for Original Medicare (Parts A and B)

Before there is a denial: prior authorization

Most Medicare Advantage plans require approval before imaging, radiation, surgery and infused drugs. Getting a fast answer here is worth more than winning an appeal later, because treatment has not been delayed yet. These are the deadlines your plan is held to.

How long a Medicare Advantage plan has to decide a prior authorization request.
Kind of requestDeadline
Standard request for care that needs prior authorizationShortened from 14 days as of January 1, 2026.7 calendar days
Expedited request for careYour plan must expedite whenever waiting could seriously harm your health. If your oncologist says so, the plan has to grant it.72 hours
Standard request for a Part B drugCannot be extended.72 hours
Expedited request for a Part B drugCannot be extended.24 hours

Being discharged too soon? That is a different, much faster appeal

If you are being discharged from a hospital, skilled nursing facility, home health agency, or hospice and you think it is too soon, this is a separate same-day appeal — not the five-level process.

Call the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for your state before you leave. The phone number is printed on the notice the facility must give you.

If you file by the deadline on that notice, you generally are not responsible for the cost of the extra days while the review is pending.

Medicare’s guidance on fast appeals

What makes an appeal work

  • A letter from your oncologist is worth more than anything you write yourself. Ask for a letter of medical necessity that names the guideline or evidence supporting the treatment, and says specifically why the alternative the plan wants is not appropriate for you. Most practices have someone whose job this is — ask for the prior authorization coordinator.
  • Read the denial for the actual reason. Plans must tell you why. “Not medically necessary” and “missing documentation” call for completely different responses, and a surprising number of denials are administrative rather than clinical.
  • Keep a log. Date, time, who you spoke to, reference number, what they said. Appeals are won on paper trails, and you will not remember by week three.
  • Ask for it in writing every time. A verbal denial is not appealable in the same way and cannot be relied on.
  • Get free help. A SHIP counselor will work through an appeal with you at no cost. So will the Medicare Rights Center and the Patient Advocate Foundation.

You can also file a complaint about a plan directly with Medicare at 1-800-MEDICARE (1-800-633-4227). That is separate from an appeal and does not extend any deadline, but plans do respond to it. If the problem is a bill rather than a refusal, see help paying costs.

Free, and nobody is selling you anything

Talk it through with a Medicare counselor

Every state has a State Health Insurance Assistance Program — trained counselors who sit down with you one-on-one, go through your own medications and doctors, and help you work out what your options actually cost. It is free, it is confidential, and they earn nothing whichever plan you choose. If you only do one thing on this page, do this one.

Find your state’s counselorOr call the national line: 1-877-839-2675