This guide explains how to win a Medicare appeal, outlines each step of the process, answers frequently asked questions, and provides a sample appeal letter you can customize.
If Medicare has denied coverage for a healthcare service, medical device, or prescription, you’re not alone. Each year, millions of claims are denied but many are reversed when appealed. Whether you’re trying to secure a mobility scooter, rehab stay, or prescription drug, understanding the appeals process and submitting the right documentation can dramatically improve your chances of success.
Understanding Medicare Denials
According to a 2022 KFF report, Medicare Advantage insurers denied over 2 million prior authorization requests in 2021. Only 11% of those denials were appealed but 82% of those appeals were successful (KFF report).
Common reasons for Medicare denials include:
- The service or item isn’t considered “medically necessary”
- The provider is out-of-network (Medicare Advantage plans)
- You’ve exceeded coverage limits (e.g., days in skilled nursing)
- Your medication isn’t on the plan’s formulary (Part D)
- There was a billing or documentation error
If you disagree with a denial, you have the right to appeal—and if you build a strong case, the odds are in your favor.
How to Know If You Were Denied
You’ll receive a notice explaining the denial:
- Original Medicare: You’ll get a Medicare Summary Notice (MSN) every 3 months
- Medicare Advantage or Part D: You’ll receive an Explanation of Benefits (EOB), typically monthly
These notices list which services were denied, the reason for denial, and how to appeal. If you didn’t receive a notice but believe a service was denied, contact 1-800-MEDICARE or log in to MyMedicare.gov.
Step-by-Step: How to Appeal a Medicare Denial
Step 1: Review the Denial
- Check the denial reason
- Note the date—it determines your appeal deadline
Step 2: File a Level 1 Appeal – Redetermination
- Deadline: Within 120 days of the denial
- Where to Send: The address listed on your denial notice or MSN
Include:
- A written explanation of why the service is necessary
- Supporting medical documents (doctor’s note, prescription, test results)
Tip: Keep a copy and send via certified mail.
Step 3: Wait for a Decision
Medicare usually responds within 60 days. If your appeal is denied again, proceed to Level 2.
Step 4: File a Level 2 Appeal – Reconsideration
- Deadline: Within 180 days of the Level 1 denial
- Who Reviews: An independent contractor (not Medicare)
You may submit additional documentation or clarification.
Step 5: Keep Going If Necessary
If your appeal is still denied, you can continue through the remaining levels:
- Level 3: Administrative Law Judge (ALJ) Hearing – claim must exceed $190
- Level 4: Medicare Appeals Council
- Level 5: Federal District Court – claim must exceed $1,840
Most cases resolve before Level 3, but you’re entitled to go as far as needed.
What to Include in Your Appeal
To build the strongest case:
- A letter of medical necessity from your doctor
- Relevant medical records and history
- A prescription or evaluation from a specialist
- Clear, factual language (avoid emotional or vague wording)
- An explanation addressing the specific reason for denial
Missed the deadline? Include a written explanation for why it was late. Medicare accepts late appeals for “good cause” (e.g., illness or mail errors).
Sample Medicare Appeal Letter (Mobility Scooter)
Date: [Insert Date]
To:
Pre-Service Appeals Department
[Medicare Administrative Contractor Name]
[Address]
[City, State ZIP Code]
Re: [Patient’s Name]
Medicare Number: [Insert Medicare ID]
Claim/Reference Number: [Insert Claim or Denial Reference Number]
Subject: Request for Redetermination – Denial of Coverage for [Item or Service, e.g., Mobility Scooter]
Dear Appeals Reviewer,
I am submitting a first-level appeal on behalf of [Patient’s Full Name] regarding the denial of Medicare coverage for a medically necessary [device/service], as outlined in the attached denial notice. I respectfully request a redetermination of this decision.
The original denial, issued on [date], stated that the request was denied due to [insert reason from denial notice, e.g., “not medically necessary”]. I believe this decision does not reflect the full scope of [Patient’s Name]’s medical condition or the need for this equipment, and I am providing additional documentation to clarify the necessity of this request.
[Patient’s Name] is currently under treatment for [diagnosis, condition, and brief clinical description including ICD-10 code if available]. Their condition significantly restricts daily functioning and mobility. Without access to a [device/service], [he/she/they] face serious health risks, including [describe risk or consequence, such as increased falls, loss of independence, or injury].
Supporting documentation includes:
- Letter of medical necessity from Dr. [Insert Name]
- Physical therapy evaluation
- Prescription for the [device/service]
- Relevant medical records
I am requesting a reconsideration of the denial and ask that Medicare approve coverage based on the medical evidence provided.
Thank you for your time and consideration.
Sincerely,
[Your Name]
[Your Relationship to the Patient, if applicable]
[Phone Number]
[Email Address]
Frequently Asked Questions
What is the success rate of Medicare appeals?
About 82% of appeals are fully or partially successful when pursued beyond the first denial (KFF Source).
How long does an appeal take?
Usually 60 days per level, but hearings (Level 3 and above) may take longer.
Can someone help me appeal?
Yes. You can appoint a family member, friend, or attorney. You can also contact your local SHIP (State Health Insurance Assistance Program) for free support.
Can I still appeal if I signed an Advance Beneficiary Notice (ABN)?
Yes. You can still appeal even if you agreed to pay by signing an ABN.
What if I miss my deadline?
Medicare allows late appeals if you explain the delay and have a valid reason (like illness or a mail issue).
Final Thoughts
Winning a Medicare appeal isn’t just possible, it’s common when you submit the right documents and follow the correct process. Whether you’re appealing a denial for rehab, home health, prescriptions, or equipment like a wheelchair or mobility scooter, act quickly, stay organized, and don’t give up.
Need help? Call 1-800-MEDICARE or contact your local SHIP office for free support.