Medicare Appeals: Can Favorable Decisions Be Overturned?

There are five levels of appeal for Medicare. If you disagree with a coverage or payment decision, you can file an appeal. The first level of appeal is a Redetermination. If you are dissatisfied with the Qualified Independent Contractor's (QIC) reconsideration decision, you may request a hearing before an Administrative Law Judge (ALJ) with the Office of Medicare Hearings and Appeals (OMHA). If the ALJ's decision is unfavorable, you can request a review by the Medicare Appeals Council. If you are still unhappy with the decision, you may be able to take your case to a federal court. So, while it is possible to appeal a favorable decision by an ALJ, it is not clear why one would want to do so.

Appealing an Administrative Law Judge (ALJ) decision

There are five levels of appeal in Original Medicare. If you disagree with the decision made at any level of the process, you can usually go to the next level.

The third level of appeal involves a decision by the Office of Medicare Hearings and Appeals (OMHA). If you are dissatisfied with the Qualified Independent Contractor's (QIC's) reconsideration decision, you may request a hearing before an Administrative Law Judge (ALJ) with the OMHA. A request for an ALJ hearing must be filed with OMHA within 60 days of receipt of the reconsideration decision.

If the ALJ's decision is unfavorable, you can appeal to the Medicare Appeals Council (the Council). To do this, you must fill out a "Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal" form. This form should include your name, Medicare Number, the specific item(s) and/or service(s), the specific date(s) of service you're appealing, a statement describing what you disagree with in the ALJ's decision, and the date of the decision.

If you do not wish to have a hearing, you may waive your right to an ALJ hearing by filling out Form OMHA-104 and submitting it with your request for a hearing. However, an ALJ may still determine that a hearing is necessary to decide your case.

The fourth level of appeal involves a review by the Medicare Appeals Council. If you wish to request this level of appeal, follow the directions in the ALJ's hearing decision from the third level of appeal.

Requesting a hearing with an ALJ

If you disagree with a decision made at any level of the Medicare appeals process, you can usually move on to the next level. There are five levels of appeal.

To request a hearing with an Administrative Law Judge (ALJ), you must meet the "amount in controversy" (AIC) requirement. The AIC requirement is the minimum dollar amount of your case, which is recalculated and published annually. For 2025, the minimum dollar amount is $190.

Your request for a hearing must be filed within 60 days of receiving the Level 2 appeals decision. If you miss the 60-day deadline, you must explain in writing why your request is late and ask the OMHA adjudicator to extend the deadline. If the OMHA adjudicator finds good cause for missing the deadline, the time period for filing the hearing request may be extended.

You can file your appeal request online or by mail. If you file by mail, you must also send a copy of the Request for Hearing to the other parties who received a copy of the reconsideration that you are appealing.

Your request for hearing must list all claims to be aggregated and be filed within 60 calendar days after receipt of all reconsiderations being appealed. The OMHA adjudicator must determine that the claims involve similar or related services.

The Hearing

Once your request for a hearing has been accepted, the ALJ will set the time and place for your hearing. You will be sent a Notice of Hearing with the date, time, and location of your hearing at least 20 days in advance. A hearing will generally be held by telephone, unless you are an unrepresented beneficiary or enrollee. However, an in-person hearing may be held if the ALJ determines the circumstances of the appeal warrant it.

Waiving the Hearing

If you do not wish to have a hearing, you can waive your right to an ALJ hearing by filling out the "Waiver of Right to an Administrative Law Judge (ALJ) Hearing" form (Form OMHA-104) and submitting it with your request for a hearing. An ALJ may still determine that it is necessary to hold a hearing, even if all the parties have waived the right to appear.

ALJ hearing procedures

If you are seeking a level 4 appeal, you must follow the directions in the Administrative Law Judge (ALJ) hearing decision you received in the level 3 appeal.

There are two ways to request a Medicare Appeals Council (Appeals Council) review:

• Fill out a "Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal" form.
• Submit a written request to the Appeals Council that includes:

• Your name and Medicare Number.
• If you have appointed a representative, include their name.
• The specific item(s) and/or service(s) and specific date(s) of service you're appealing.
• A statement describing what you disagree with in the ALJ's decision and why.
• The date of the ALJ decision.

If you are requesting that your case be moved from the ALJ to the Appeals Council because the ALJ has not issued a timely decision, send your request to the OMHA address listed on the QIC's reconsideration notice. If you know that your case was assigned to an OMHA adjudicator, send your request to the OMHA address listed on the reconsideration notice.

You can ask OMHA to make a decision without holding a hearing, based only on the information in your appeal record. The ALJ or attorney adjudicator may also issue a decision without holding a hearing if the appeal record supports a decision that is fully in your favor. To ask OMHA to make a decision without a hearing, submit the information required for an ALJ hearing and one of the following:

• The "Waiver of Right to an Administrative Law Judge (ALJ) Hearing" form (Form OMHA-104).
• A written request stating that you do not wish to appear before an ALJ at a hearing (including a hearing held by phone or video-teleconference).

Appealing an unfavourable ALJ decision

If you receive an unfavorable decision from an Administrative Law Judge (ALJ), you can file an appeal. The appeal is filed with the appeals council, who will review the decision to determine if there were mistakes made in the decision or at the hearing that affected the outcome of your case.

The unfavorable decision will contain information on how to file an appeal. You will usually have 60 days from the date of receiving an unfavorable decision to submit an appeal.

When reviewing your unfavorable decision and considering filing a request for review, certain aspects must be missing or incorrect to justify appealing to the Appeals Council. For example, did the ALJ ignore important medical conditions, medications, side-effects, or specific medical evidence? Were medical records incomplete or insufficient? Did the ALJ ignore the opinion of a supporting doctor?

If your appeal is unsuccessful, the appeals council will dismiss the case and decide not to review it, or deny the appeal. If your appeal is successful, the appeals council may approve the case and calculate your benefits or remand the case. If your case is remanded, it will be sent back to the ALJ for another hearing.

Medicare Appeals Council review

The Medicare Appeals process has five levels. If you disagree with the decision made at any level, you can usually go to the next level.

The fourth level of appeal is a review by the Medicare Appeals Council (MAC). If a party is dissatisfied with the Office of Medicare Hearings and Appeals' (OMHA) decision or dismissal, they may request a review by the MAC. If the OMHA adjudication period has elapsed without an Administrative Law Judge (ALJ) or attorney adjudicator issuing a decision or dismissal on the request for a hearing, the appellant party can escalate the appeal to the Council.

The request for review must be filed in writing with the Council within 60 days of receiving the dismissal notice. The appellant must also send a copy of the request for review to the other parties who received notice of the dismissal. If the appellant files a request to escalate an appeal to the Council because OMHA has not completed the action on the request for a hearing within the adjudication deadline, the request for escalation must be filed with OMHA, and the appellant must also send a copy of the request for escalation to the other parties who were sent a copy of the Qualified Independent Contractor (QIC) reconsideration.

The Council's dismissal of a request for a hearing is binding and not subject to judicial review. If the Council does not issue a decision, dismissal, or remand the case to an ALJ or attorney adjudicator within the adjudication period, the appellant may send a request to the Council asking that the appeal be escalated to a Federal district court.

The Council's review process can be initiated in one of two ways:

• Fill out a "Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal" form.
• Submit a written request to the Appeals Council that includes: your name and Medicare Number; the name of your representative, if you've appointed one; the specific item(s) and/or service(s) and specific date(s) of service you're appealing; a statement describing what you disagree with in the ALJ's decision and why; and the date of the ALJ decision.

Frequently asked questions