FOR PEOPLE AND TEAMS · DENIALS

A denial has a next step. This is it.

Choose the coverage and the reason on the notice. The letter cites the rule that gives you the right to appeal, states the deadline, argues the point the payer raised, and lists what to enclose. Everything you type stays on this device.

The denial

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Who is appealingCoverageReason on the denialPatient nameMember IDClaim numberService and codeDate of serviceDate on the denial noticeProvider (optional)Appeals address (from the notice)

Your letter

November 2, 2026

Original Medicare (Part B)
Appeals department

Re: Request for redetermination
Patient: [patient name]
Member ID: [member ID]
Claim number: [claim number]
Service: [service and code]
Date of service: [date]
Denial notice dated: [date on the denial]

To whom it may concern,

I am appealing the denial of the claim above. The notice gives the reason as "not medically necessary". The service was medically necessary for the diagnosis on the claim. The treating clinician's records document the condition, the clinical findings, the treatments tried before this service, and why this service was the appropriate next step. The coverage policy you applied does not exclude this service for this diagnosis; I ask that the claim be reviewed by a clinician in the same specialty.

This appeal is filed within the 120-day window that applies to this coverage (42 CFR 405.940–405.958). Please review the enclosed documentation, reprocess the claim, and send a written decision with the specific policy basis for any part that remains denied. 

Enclosed:
- Clinician's letter of medical necessity
- Relevant clinical notes and test results
- The coverage policy (LCD, NCD or plan policy) with the applicable section marked
- Copy of the denial notice

Thank you for your attention to this matter.

Sincerely,

[patient name]
[phone number and mailing address]

Deadline and route

Enter the date on the denial notice to see your exact deadline.

Deadline120 days from the date on the Medicare Summary Notice or remittance advice. The MAC has 60 days to decide.

Your oddsOriginal Medicare does not publish a comparable overturn rate; redeterminations are decided by the MAC within 60 days.

Where to send itRequest a redetermination from the Medicare Administrative Contractor (MAC) named on the Medicare Summary Notice. Use form CMS-20027 or a signed letter with the same information.

Rule42 CFR 405.940–405.958

Deadlines run from the date on the notice, not the date you read it. When the notice states a different deadline, the notice governs. Send appeals in a way that gives you proof of the date.

BEFORE YOU SEND

Enclose what the reason needs.

Clinician's letter of medical necessity. Relevant clinical notes and test results. The coverage policy (LCD, NCD or plan policy) with the applicable section marked. Keep a copy of everything.

RVU-based Medicare benchmark, before payer adjustments, OPPS caps, sequestration, and patient cost sharing. An estimate, not a payment guarantee.