Medicare Advantage appeals: the five levels explained
Medicare Advantage (Part C) denials follow a specific five-level appeal track set by 42 CFR Part 422. Here is what each level looks like and the deadlines that apply.
How a Part C appeal starts
A Medicare Advantage denial is called an adverse organization determination. You request reconsideration in writing within 60 days of the notice. Standard reconsiderations are decided within 30 days for pre-service items and 60 days for payment.
Expedited reconsiderations apply when waiting could seriously jeopardize your life, health, or ability to regain function — decision within 72 hours.
Source: 42 CFR 422 Subpart M. See https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-M.
The five levels
Level 1 — Plan reconsideration. The plan reviews its own decision. If it upholds the denial in whole or part, the case is automatically forwarded to Level 2.
Level 2 — Independent Review Entity (IRE). CMS contracts a qualified independent contractor (currently MAXIMUS Federal Services) to review the case de novo.
Level 3 — Office of Medicare Hearings and Appeals (OMHA). Administrative Law Judge hearing. The amount in controversy threshold for 2026 applies — check the current CMS notice.
Level 4 — Medicare Appeals Council review.
Level 5 — Federal district court, when the amount in controversy threshold is met.
What strengthens a Part C appeal
Cite the specific National Coverage Determination (NCD), Local Coverage Determination (LCD), or Medicare Benefit Policy Manual section that supports coverage. CMS publishes these at cms.gov.
Get a written statement from the treating physician explaining medical necessity in Medicare's terms (reasonable and necessary for diagnosis or treatment).
Upload the denial letter. Free analysis first, finished letter second.
FAQ
Do I file with Original Medicare or with my plan?+
Medicare Advantage appeals start with the plan, not with Original Medicare. The plan must forward an upheld denial to the IRE automatically.
What is the expedited deadline?+
72 hours from the request, with a possible 14-day extension only if you ask for it or the plan justifies it as in your interest.
More guides
- How to write a health insurance appeal letter
- Internal appeal vs external review: what is the difference
- Expedited appeals: when to ask for an urgent review
- The No Surprises Act and out-of-network bills