There are five levels in the Medicare claims appeal process:

Level 1: Your Health Plan: If you disagree with a Medicare coverage decision, you may request your health plan to redetermine your claim.

Level 2: An Independent Organization: If you disagree with the decision in Level 1, you may request a reconsideration by an independent organization.

Level 3: Office of Medicare Hearings and Appeals (OMHA): If you disagree with the Level 2 decision or dismissal, you may request that an OMHA adjudicator review the action.

Level 4: The Medicare Appeals Council: If you disagree with the OMHA adjudicator's decision, you may request the Medicare Appeals Council review the decision.

Level 5: Federal Court: If you disagree with the Medicare Appeals Council decision, you may seek a review of your claim in Federal District Court.

What to Expect in a Medicare Federal District Court Appeal

(After a Medicare Appeals Council (MAC) Decision)

Once a case reaches federal court, the nature of the process changes dramatically. It no longer feels like an administrative or insurance appeal—it becomes a formal lawsuit against the federal government under the Medicare statute.

Here is what you can expect at each stage:

1. You Are Suing the Secretary of Health & Human Services (HHS)

The case name will look like:

(Your Name) v. Xavier Becerra, Secretary of Health & Human Services

This is a civil action, filed in the U.S. District Court that covers your state.

You are not suing your insurance company, the plan, the pharmacy, or the Medicare contractor—only HHS, because Medicare coverage decisions ultimately fall under that federal authority.

2. Federal Court Does NOT Re-Hear Your Case

This is the biggest surprise for people.

Federal judges do NOT:

• take new evidence

• review new medical records

• let you tell your story again

• consider facts that weren’t in the ALJ/MAC record

Federal district court review is limited to the evidence and arguments already in the administrative record.

The judge’s ONLY job is to decide whether the Medicare Appeals Council:

• applied the law correctly, and

• made a decision supported by “substantial evidence.”

This is a legal review, not a medical review.

3. The Case Is Decided Mostly on Written Briefs

There is almost never an in-person hearing.

The process looks like this:

Step 1: You file a Complaint

This document:

• Names the defendant (HHS Secretary)

• States the basis for federal jurisdiction (42 U.S.C. § 405(g))

• States why the MAC decision was legally wrong
  
  

Step 2: HHS Files the Administrative Record

This is a large file including:

• ALJ hearing transcript

• ALJ decision

• All evidence submitted

• The Medicare Appeals Council decision

• All prior appeal documents

This becomes the only evidence the judge reviews.

Step 3: Briefing

Usually:

• Plaintiff’s Motion for Summary Judgment / Opening Brief

• HHS Response Brief

• Plaintiff’s Reply Brief
  
  

These documents argue issues like:

• Were Medicare rules correctly applied?

• Did the ALJ ignore relevant evidence?

• Did the MAC use the wrong legal standard?

• Was the decision “arbitrary and capricious”?

4. Possible Outcomes

The district court can:

1. Affirm the MAC decision

Upholds the denial (least favorable)

2. Reverse the MAC decision

Orders Medicare to cover the item/service (best outcome)

3. Remand the case back to the MAC or ALJ

Most common outcome
The judge sends the case back because:

• the ALJ didn’t consider key evidence

• the MAC misapplied policy

• the record is incomplete

• the reasoning was inadequate

On remand, a new ALJ hearing may be required.

5. Timeline – What to Expect

Federal Medicare appeals move slowly:

• Filing complaint → done immediately

• HHS files the administrative record → 60–120 days

• Briefing schedule → 3–4 months

• Judge’s decision → 6–12 months after briefing

Total: 12–24 months for the final ruling.

6. Standard of Review Is Very High

This is important:

A federal judge MUST defer to the Medicare Appeals Council unless:

• there is a clear legal error,

• the decision contradicts Medicare law, OR

• the findings lack “substantial evidence.”

Your burden is not to show the judge that the treatment is medically necessary—only that the MAC was wrong as a matter of law.

7. You Can Represent Yourself (“Pro Se”)

But it is challenging because federal court:

• requires strict formatting

• uses legal standards

• expects citations to statutes/regulations

• must follow federal civil procedure rules
  
  

If representing yourself, the judge will give some leniency, but you still must follow court rules.

Many people hire an attorney just for this phase because federal litigation is procedural-heavy.

8. Cost Expectations

There is:

• a federal filing fee (about $405, as of Dec. 2025)

• possible costs for printing/serving documents

• attorney’s fees only if you hire counsel

If you win, you may be eligible to recover attorney’s fees under the Equal Access to Justice Act (EAJA) if the government’s position wasn’t substantially justified.

9. What You Should Prepare Before Filing

Even though you can’t add evidence later, you can prepare your legal arguments. Make sure you have:

• The ALJ and MAC decision

• Where they applied incorrect Medicare policy

• Why their reasoning was inadequate

• How they misunderstood the record

• Regulatory citations showing coverage should have been approved

List of Certified Independent Dispute Resolution Entities - Level 2 Appeals