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Appeals Overview

Guidance for the Part D appeals process if a plan sponsor issues an unfavorable coverage determination.

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: June 28, 2020

If a plan sponsor issues an unfavorable or partially favorable coverage determination, the decision may be appealed through the Part D appeals process.

There are five successive levels of appeal in the Medicare Part D program.

  1. Redetermination by the Part D Plan Sponsor
  2. Reconsideration by the Independent Review Entity
  3. Hearing by an Administrative Law Judge  
  4. Review by the Medicare Appeals Council
  5. Review by a Federal District Court

A decision may be appealed to the next level of appeal when the lower appeal entity issues a decision that is unfavorable to the enrollee.  Each unfavorable decision will contain the information needed to file an appeal request.

Use the navigation tool on the left side of this page to link to subpages that contain detailed information about each of the five levels of appeal.

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.