Rules & Rights
Appeal
Quick answer
An appeal is your formal request to change a coverage or payment decision made by Medicare, a Medicare Advantage plan, or a Part D plan. Medicare has five levels of appeal.
Plain-English definition
For Part D, you must first request a coverage determination before appealing.
Why it matters
Many appeals are decided in the beneficiary's favor.
A simple example
Your plan denies coverage of an imaging study. You appeal, and it's overturned.
Common mistakes & misconceptions
Related terms
Grievance
A grievance is a formal complaint to your plan about service quality, access, or the appeals process — not about coverage decisions themselves.
Coverage Determination
A coverage determination is the plan's formal decision about whether a drug is covered, how much you'll pay, and any requirements like prior authorization.
Frequently asked questions
How long do I have to appeal?+
Deadlines depend on the level of appeal — usually 60 days from the notice.
Sources & references
📚 Where this information comes from
- Medicare.gov — official U.S. government site for people with Medicare ↗Primary source for benefits, enrollment periods, and plan comparison.
- CMS.gov — Centers for Medicare & Medicaid Services ↗Federal rulemaking, program updates, and official guidance.
- Social Security Administration — Medicare enrollment & premiums ↗Enrollment, premium withholding, and IRMAA determinations.
When you're ready, compare plans on your own terms
See Medicare Advantage plans from the insurance companies we represent, or walk the course with a licensed agent whenever you'd like a second set of eyes.
We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.
Medicare Caddies is an independent insurance agency. We are not affiliated with, endorsed by, or connected to the U.S. government, the federal Medicare program, or the Centers for Medicare & Medicaid Services (CMS). We help compare Medicare Advantage plans from the insurance companies we represent, and we don't offer every plan available in your area.