PAYER APPEAL GUIDE · GOVERNMENT

How to appeal a Medicare Part B denial

Medicare Part B claims are adjudicated by a Medicare Administrative Contractor (MAC) for your region, and the appeal path is a five-level process fixed by federal regulation (42 CFR Part 405, Subpart I) — not by a private plan's discretion. For an independent practice the first two levels do most of the work: a MAC redetermination, then a reconsideration by an independent contractor. The rules, forms, and clocks are uniform nationwide, which makes these appeals highly systematizable.

The most common Medicare Part B denials

  • Medical-necessity denials measured against a Local Coverage Determination (LCD) or National Coverage Determination (NCD)
  • Missing or unsupported documentation on the initial determination (the Medicare Remittance Advice)
  • Coding, bundling, and NCCI edits, including modifier requirements specific to Medicare
  • Frequency, medically-unlikely-edit (MUE), and non-covered-service denials
  • Signature, ordering-provider, or ADR (additional documentation request) failures

How to appeal to Medicare Part B

1
Level 1 — Redetermination: request it from the MAC within 120 days of receiving the initial determination (the remittance advice), using Form CMS-20027 or the MAC's equivalent; the MAC generally decides within 60 days
2
Level 2 — Reconsideration: if the redetermination is unfavorable, file with the Qualified Independent Contractor (QIC) within 180 days using Form CMS-20033; submit all evidence here, because new evidence at later levels can require good cause
3
Level 3 — ALJ hearing before the Office of Medicare Hearings and Appeals, subject to an amount-in-controversy threshold that CMS updates annually; Level 4 — Medicare Appeals Council; Level 5 — federal district court
4
Deadlines run from the date of receipt of each decision (presumed five days after the notice date unless shown otherwise); the LCD/NCD cited on the denial is the standard the appeal must meet

What wins with Medicare Part B

  • Anchor every medical-necessity appeal to the exact LCD/NCD cited and show, point by point, that the documentation meets its coverage criteria
  • Put the full record in at the reconsideration (Level 2) — the QIC record is the one the later levels build on, and adding evidence afterward gets harder
  • Watch the 120-day redetermination clock from the remittance date; Medicare deadlines are firm and a late request needs good cause
  • For ADR-driven denials, respond to the documentation request itself with signed, dated, order-supported records rather than opening a fresh appeal

Common questions

How do I appeal a Medicare Part B denial?

Medicare Part B claims are adjudicated by a Medicare Administrative Contractor (MAC) for your region, and the appeal path is a five-level process fixed by federal regulation (42 CFR Part 405, Subpart I) — not by a private plan's discretion. For an independent practice the first two levels do most of the work: a MAC redetermination, then a reconsideration by an independent contractor. The rules, forms, and clocks are uniform nationwide, which makes these appeals highly systematizable. The path: level 1 — Redetermination: request it from the MAC within 120 days of receiving the initial determination (the remittance advice), using Form CMS-20027 or the MAC's equivalent; the MAC generally decides within 60 days; level 2 — Reconsideration: if the redetermination is unfavorable, file with the Qualified Independent Contractor (QIC) within 180 days using Form CMS-20033; submit all evidence here, because new evidence at later levels can require good cause; level 3 — ALJ hearing before the Office of Medicare Hearings and Appeals, subject to an amount-in-controversy threshold that CMS updates annually; Level 4 — Medicare Appeals Council; Level 5 — federal district court; deadlines run from the date of receipt of each decision (presumed five days after the notice date unless shown otherwise); the LCD/NCD cited on the denial is the standard the appeal must meet.

What are the most common Medicare Part B denials?

Medical-necessity denials measured against a Local Coverage Determination (LCD) or National Coverage Determination (NCD); Missing or unsupported documentation on the initial determination (the Medicare Remittance Advice); Coding, bundling, and NCCI edits, including modifier requirements specific to Medicare; Frequency, medically-unlikely-edit (MUE), and non-covered-service denials; Signature, ordering-provider, or ADR (additional documentation request) failures.

How does Volari handle Medicare Part B denials?

Volari identifies your written-off Medicare Part B denials, builds each appeal with the payer-specific argument and documentation, files it through Medicare Part B's process, and follows it to payment. You pay 25% only on what's recovered.

Where Volari fits: For Medicare Part B, Volari works on a flat, non-contingent fee — the arrangement 42 CFR requires on government claims. It reconciles each MAC remittance, files the redetermination and QIC reconsideration on the federal forms against the governing LCD/NCD, and holds the statutory clocks so winnable claims don't lapse.

Other payers
UnitedHealthcare →UnitedHealthcare E/M Downcoding →UnitedHealthcare Prior Authorization →Aetna →Aetna Medical Necessity (Clinical Policy Bulletins) →Cigna →Cigna Modifier 25 Policy →Blue Cross Blue Shield →Anthem Blue Cross →Humana →Humana Medicare Advantage Denials →EviCore →Carelon (formerly AIM Specialty Health) →UMR →Meritain Health →Oscar Health →HCSC (BCBS of IL, TX, OK, NM, MT) →Ambetter (Centene) →Anthem / Elevance E/M Downcoding →Aetna Claim-Edit & Downcoding Policies →

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