How a plan's reconsideration (Level 1 appeal) works
Checked against the current rules on September 18, 2026.
A reconsideration is the first level of appeal — asking the plan to take another look at its own denial. It comes with real procedural protections, not just a second look by the same reviewer.
Source: 42 CFR Part 422, Subpart M — Grievances, Organization Determinations and Appeals.
If your reconsideration involves a medical necessity question, a physician with expertise in the relevant field — not the original decision-maker — has to review it.42 CFR 422.590
The plan must decide within 30 calendar days for a service you haven't received yet, 60 days for a payment request, or 72 hours if expedited.42 CFR 422.590
If the plan doesn't decide in time, or upholds its own denial in whole or in part, it must automatically forward the case to the Independent Review Entity — you don't have to file anything to trigger this.42 CFR 422.590
The physician-reviewer requirement, in practice
This isn't a formality — it means the second look at a medical-necessity denial can't be done by the same non-clinical reviewer, or even the same specialty mismatch, that produced the original denial. A physician with real expertise in the relevant condition has to be the one reviewing it.
A reconsideration letter that clearly states the medical question at issue makes it easier for the plan to route the case to a reviewer with the right expertise — vague or incomplete letters risk a slower, less-informed review.
A reconsideration request doesn't require a specific form — a letter is enough, sent wherever the denial notice itself says to send it. What matters is that it clearly identifies the enrollee, the denial being challenged, and the basis for disagreeing with it, ideally naming the specific rule the denial should have followed.
Sending the reconsideration promptly, well before the 65-day deadline, gives the plan the most room to actually apply its own full timeframe correctly rather than rushing a late-arriving request.
New evidence — a physician's letter, updated test results, records not included with the original request — can be submitted at reconsideration even if it wasn't part of the original organization determination. This level is a genuine fresh look, not limited to only what the plan already saw.
Sources — last checked September 18, 2026
- 42 CFR 422.590as of September 18, 2026
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
