How to Appeal a Medicare Advantage (Part C) or Part D Denial

If you are enrolled in a private Medicare Advantage (Part C) or Part D plan, receiving a denial can be a frustrating experience. While the overall appeals structure is similar to Original Medicare (Parts A and B), there are key differences in the process, deadlines, and who reviews your case. It is crucial to understand these distinctions to successfully challenge a denial.

Level 1 Appeal: Your Plan's Reconsideration or Redetermination

This is the first step you take after your plan denies coverage for a service or a prescription drug.

  • The Reviewer: The appeal is reviewed internally by your Medicare Advantage or Part D plan. The plan is required to conduct this review within a specific timeframe.

  • The Appeal Name: For Medicare Advantage (Part C), this is called a Reconsideration. For a Part D plan, it is a Redetermination.

  • The Deadline: You must file your request with the plan within 60 calendar days from the date on your denial notice.

  • Key Documents: You will need to submit a written request along with a copy of your plan's denial notice and any supporting evidence, such as a letter of medical necessity from your doctor.

Level 2 Appeal: The Independent Review

If your plan upholds its denial at Level 1, your case moves to an independent entity that is not associated with your plan.

  • The Reviewer: This appeal is reviewed by an Independent Review Entity (IRE), which is a Medicare contractor tasked with performing impartial reviews for Parts C and D.

  • The Appeal Name: At this level, the appeal for both Parts C and D is called a Reconsideration.

  • The Deadline: You must file your request with the IRE within 60 calendar days from the date on your plan's Level 1 denial notice.

The appeals process continues with similar steps for all types of Medicare coverage after Level 2. Your next options, if applicable, would be to request a hearing before an Administrative Law Judge, review by the Medicare Appeals Council, and finally, Judicial Review in Federal District Court.