.png)
When government agencies make decisions about your benefits, you have the right to appeal if you disagree. This guide explains the appeals processes for Social Security decisions (including retirement and disability) and Medicare denials (including medication exceptions).
If you disagree with a decision made by the Social Security Administration (SSA) about your benefits, you have the right to appeal. The appeals process gives you the opportunity to present your case and potentially reverse an unfavorable decision.
Social Security provides four levels of appeal. You don't necessarily need to go through all levels—many cases are resolved at earlier stages. Each level has specific procedures and timeframes you must follow.
The first step in appealing any Social Security decision is to request a reconsideration. This is a complete review of your claim by someone who did not participate in the original decision.
If you disagree with the reconsideration decision, you can request a hearing before an Administrative Law Judge (ALJ). The ALJ had no part in the original decision or reconsideration.
If you disagree with the ALJ's decision, you can request that the Appeals Council review your case. The Appeals Council looks at all requests but may deny a request if it believes the ALJ's decision was correct.
If you disagree with the Appeals Council's decision, or if the Appeals Council denies your request for review, you can file a civil action in a Federal district court.
If you're appealing a disability claim denial, you'll need to provide additional information about your medical condition.
When appealing decisions about retirement benefits, spousal benefits, or other non-disability issues, focus on:
For more information about the appeals process, visit the SSA's Official Hearings and Appeals Website or call 1-800-772-1213 (TTY 1-800-325-0778).
When Medicare or your Medicare Advantage plan denies coverage for a service, procedure, or medication, you have the right to appeal that decision. This section explains the different appeals processes for Original Medicare, Medicare Advantage plans, and medication exceptions.
If you have Original Medicare and disagree with a coverage or payment decision, you can file an appeal. The process includes five levels:
What it is: A complete review of your claim by Medicare contractors who did not participate in the original decision.
What it is: If you disagree with the redetermination, your appeal is reviewed by an independent contractor.
These levels follow the same general process as described in the Social Security appeals section, with specific Medicare-related considerations.
Medicare Advantage (MA) plans have their own appeals process that differs from Original Medicare.
What it is: A review of the denial by your Medicare Advantage plan.
What it is: If your plan upholds its denial, your case is automatically forwarded to an Independent Review Entity.
These follow the same process as Original Medicare appeals.
Medicare Advantage plans often require prior authorization for certain services or treatments. If your plan denies prior authorization:
If Medicare Part D or your Medicare Advantage prescription drug plan denies coverage for a medication, you can request an exception or file an appeal.
Request coverage for a drug not on your plan's formulary (drug list).
Key points:
Request to pay a lower copay for a non-preferred drug.
Key points:
Request to waive restrictions like quantity limits, step therapy, or prior authorization.
Key points:
If your exception request is denied, you can appeal through the same five-level process used for other Medicare appeals:
Important: For expedited appeals involving medications you haven't received yet, each level has accelerated timeframes to ensure timely decisions.
For more information about Medicare appeals, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
Before he became the go-to guru for government benefits on his YouTube channel, MyGovExpert, Dr. Ed was a District Manager for the Social Security Administration. That's right, he wasn't just reading the rulebook; he was living it, managing the folks who make the decisions. If you've ever felt like SSA speaks a different language, Dr. Ed is your translator. He's seen it all, heard it all, and now he's here to share that invaluable insider experience with you, cutting through the red tape with a healthy dose of common sense (and maybe a terrible joke or two).
But his journey didn't start there. Long before navigating bureaucratic hall ways, Dr. Ed served his country with distinction as a Sergeant in the United States Marine Corps. Semper Fi! That discipline and commitment to service are still a core part of who he is today.
His dedication to public service also led him to a role as a Family Services Specialist with the Department of Social Services, giving him a broad perspective on the challenges many people face. And because he apparently doesn't believe in free time, Dr. Ed has also been shaping young minds as a University Adjunct Professor.
With a PhD to his name and a wealth of real-world experience, Dr. Ed Weir isn't just an expert; he's your expert. He's passionate about helping people understand their benefits and get what they're entitled to. So, if you're looking for some one who can explain complex government stuff in plain English, with a bit of humor and the authority that only comes from having been there, you've found your guy.
.png)
