Medicare appeals 🧭: timelines, tips, and faster decisions 🏥

🎯 Hot Take
Congress is cranking up oversight on Medicare marketing and misinformation, and KFF just dropped a practical guide to appealing denials. Translation: beneficiaries and brokers should expect closer review of how plans communicate, authorize care, and explain decisions. Don’t fear the “no” — learn the process, document well, and loop in your clinician early so you can request the right kind of review when it matters.

📰 What Changed

• Senate spotlight: A Senate Finance hearing featuring RFK Jr. highlighted bipartisan interest in stronger oversight of health misinformation and beneficiary protections, including Medicare-related issues. Expect continued attention on marketing practices, prior authorization, and consumer education. Source recap below.
• Consumer playbook drop: KFF Health News published seven practical tips for challenging denials — a solid, plain‑English checklist that Medicare Advantage and Part D members (and caregivers) can use to prepare an appeal.
• Cost pressure backdrop: High-cost drugs (hello, GLP‑1s) are putting pressure on plan budgets, which may mean tighter utilization rules and more denials that require detailed documentation to appeal.

💡 Why It Matters (Consumers)
Appeals aren’t a moonshot — they’re a structured process with timelines and levels. Results vary, but you can position your case clearly:

• Read the letter: Identify the exact denial reason and policy criteria cited.
• Call your plan, take notes: Ask for the specific rule, guideline, or Evidence of Coverage (EOC) section your case is being measured against.
• Loop in your clinician: Request a letter of medical necessity that addresses each plan criterion point by point (diagnosis, prior therapies, dosing, and clinical rationale).
• Consider “expedited” when delay risks your health:
  • Medicare Advantage services/items: Plans generally decide expedited requests in 72 hours and standard requests in 14 days, per Medicare.gov.
  • Part D drugs: Plans generally decide expedited requests in 24 hours (exigent) and standard requests in 72 hours, per Medicare.gov.
• Keep everything in writing: Save PDFs, portal screenshots, faxes, and dated notes from calls.
• Track deadlines: You generally have 60 days from the date on a decision notice to appeal to the next level (plan or external reviewer), unless you show good cause for late filing.
• Know the appeal path (simplified):
  • Medicare Advantage: Plan organization determination → Plan reconsideration (if not fully favorable, it goes to the IRE) → Administrative Law Judge (ALJ) → Medicare Appeals Council → Federal court (if applicable).
  • Part D: Plan coverage determination → Plan redetermination → Independent Review Entity (IRE) → ALJ → Medicare Appeals Council → Federal court (if applicable).
• Pro tip: Requests involving higher‑scrutiny categories (e.g., GLP‑1s, high‑cost imaging, post‑acute care) often require meticulous documentation that matches the plan’s published criteria.

💼 Why It Matters (Brokers)
Your edge this AEP is being the calm, compliant guide through prior‑auth and appeals.

• Prep your files: Keep carrier‑specific prior-auth grids, links to medical/pharmacy policies, and Evidence of Coverage references handy.
• Set expectations ethically: Educate on process and timelines; don’t promise approvals, outcomes, or savings.
• Build a fast‑appeal kit:
  • Client authorization template (and Scope of Appointment when required).
  • Clinician letter checklist mapped to policy criteria.
  • Step‑by‑step appeal timelines by product (MA vs. Part D).
• Document everything: Time‑stamp calls, portal submissions, and client consent; keep notes factual and contemporaneous.
• Train for misinformation moments: Bring credible sources (Medicare.gov, plan policies, FDA labeling) to address viral claims calmly and accurately.

✅ Next Steps
For consumers

• Save denial letters and EOBs in one folder (digital or paper).
• Ask your doctor to reference the plan’s criteria directly, not just “medically necessary.”
• If waiting could worsen your health, ask your plan about an expedited decision.
• Missed a deadline? Request consideration for “good cause” and include documentation.

For brokers

• Create a one‑page appeal roadmap per carrier and product.
• Refresh your talk track on timelines (MA vs. Part D differ).
• Flag high‑friction categories (imaging, post‑acute care, GLP‑1s) and prep documentation checklists for each.

🔢 Key Numbers

• 5 levels of Medicare appeals (MA and Part D).
• 72 hours: common expedited window for MA service requests.
• 14 days: common standard window for MA service requests.
• 24 hours expedited / 72 hours standard: common Part D coverage determination windows.
• 60 days: typical window to request the next‑level appeal after an adverse decision.
• Medicare Annual Enrollment runs Oct 15–Dec 7 — a time to compare plans if you’re dissatisfied with coverage decisions or provider fit. Compare benefits, networks, drug formularies, and utilization rules; individual results vary.

🔗 Citations

• RFK Jr. Faces Senate Finance Committee: A Live Discussion — KFF Health News (Sept 4, 2025): https://kffhealthnews.org/news/article/rfk-jr-kennedy-hhs-senate-finance-committee-hearing-recap-live-discussion-sept-4/
• Fighting a Health Insurance Denial? Here Are 7 Tips To Help — KFF Health News (Sept 4, 2025): https://kffhealthnews.org/news/article/health-insurance-denial-prior-authorization-7-tips-to-file-appeal/
• As Insurers Struggle With GLP-1 Drug Costs, Some Seek To Wean Patients Off — KFF Health News (Sept 4, 2025): https://kffhealthnews.org/news/article/glp-1-weight-loss-diabetes-drugs-cost-deprescription-medicaid-north-carolina/
• Medicare Advantage appeals (process and timelines) — Medicare.gov: https://www.medicare.gov/claims-appeals/what-if-my-medicare-advantage-plan-denies-coverage
• Part D coverage determinations, exceptions, and appeals — Medicare.gov: https://www.medicare.gov/drug-coverage-part-d/appeals-if-you-have-a-medicare-drug-plan
• Medicare appeals: overview of the 5 levels — Medicare.gov: https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal

The Marketplace Hotline is a marketing platform and not a government program. We connect individuals and brokers with licensed insurance professionals. We are not connected with or endorsed by the U.S. Government or the federal Medicare program. This content is educational, not legal advice.