How do I file an appeal with my Medicare Advantage Plan?

Dear Mustafa, 

If you have a Medicare Advantage Plan and were denied coverage for a health service or item that you already received, you can appeal – formally ask your plan to reconsider its decision. If the plan does not change its decision, you can continue the appeal and have an independent review.   

To appeal a denied health service:  

• You should receive a written notice from your plan stating that it is not covering your health service or item. Start your appeal by following the instructions on this notice. File your appeal within 60 days of the date on the notice.  
  • Read the notice carefully and identify the reason the plan gave for the denial.  
  • You can include a letter to the plan explaining why you needed the service you received and why the reasons for denial listed in the letter are inaccurate or do not apply.  
  • You may also want to ask your doctor to write a letter of support, explaining why you needed the service care and addressing the plan’s stated reasons for the denial. 
  • If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension. 
• If your appeal is successful, your service or item will be covered. If your appeal is denied, you should receive a written denial notice. Your plan should automatically forward your appeal to the next level, the Independent Review Entity (IRE). You can send the IRE additional information to respond to the denial letter. The IRE should make a decision within 60 days of the date on your plan denial notice. 
• If your appeal to the IRE is successful, your service or item will be covered. If your IRE appeal is denied and your care is worth at least $200 in 2026, you can choose to continue the appeal at the Office of Medicare Hearings and Appeals (OMHA) level. 
  • You must file your OMHA level appeal within 60 days of the date on your IRE denial letter. 
  • Instructions for what information to send to OMHA are included in the IRE decision.  
  • OMHA appeals are decided by an Administrative Law Judge (ALJ) and there may be a phone or video conference hearing in addition to the written documents.  
• If your appeal to the OMHA level is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $200 in 2026, you can appeal to the Medicare Appeals Council (Council) within 60 days of the date on your OMHA level denial letter. 
• If your appeal to the Council is successful, your care will be covered. If your appeal is denied and your health service or item is worth least $1,960 in 2026, you can appeal to the Federal District Court within 60 days of the date on your Council denial letter. Bringing an appeal case to District Court has more procedural rules, and people usually benefit from legal representation at this level. 

Hope this answers your question! 

-Marci