Your deadline
The windows are NOT uniform and they get SHORTER as you go up, which is the trap if you have read 180 days elsewhere on this site. Read from RECEIPT of each decision: redetermination 120 days (42 CFR 405.942), reconsideration 180 days (405.962), then Administrative Law Judge 60 days (405.1002) and Medicare Appeals Council 60 days (405.1102). All four read directly from the regulation.
What to do
Find out which contractor covers your region
Medicare Administrative Contractors, or MACs, decide these claims locally on a case-by-case basis. The MAC is your regulator for this purpose, and which one covers your region determines whose policy applies to you.
Look for a local coverage determination
Some contractors publish one; some decide case by case with no published policy. Ask, in writing, which policy was applied to your claim.
Check whether you are in Original Medicare or Advantage
Advantage plans run their own prior authorization and appeal process before the Medicare levels, and their deadlines are their own.
Use the five-level appeal ladder
Redetermination (120 days from receipt, 42 CFR 405.942), reconsideration (180 days, 405.962), an administrative law judge hearing (60 days, 405.1002), the Medicare Appeals Council (60 days, 405.1102), then federal court — whose window is set by the Council's own decision notice rather than by the four regulations above, so read that letter for it. Each level has its own deadline printed on the decision you receive.
Expect the fight to be about classification
The common denial is not that the care is unnecessary but that the specific procedure is cosmetic. Answer the classification, not the necessity.
Get help before the hearing level
An administrative law judge hearing rewards representation. Legal aid and organizations working on older adults' benefits take these.
If you were asked to sign an Advance Beneficiary Notice
An ABN is the Medicare-specific form that shifts financial liability to you when a provider expects Medicare may not pay. Signing one is not the end of the argument: an ABN has to be properly issued to do its work, and a defective, generic or late one is challengeable.
If you signed something at the desk that you did not understand, keep it and raise it. The question is not only whether Medicare covers the service but whether the notice that made you liable was valid.
Medicare Advantage moves one level for you
If your coverage is through a Medicare Advantage plan rather than original Medicare, one step is generally automatic: when the plan upholds its own adverse decision on reconsideration, it is required to forward the case to an independent review entity itself. You do not file that level.
Two things follow. Do not duplicate the filing, and do not assume nothing is happening because you were not asked to do anything. Ask the plan to confirm in writing that it has forwarded the case and on what date.
There is a document, and you can cite it
The policy has a number: NCD 140.9, Gender Dysphoria and Gender Reassignment Surgery, effective 30 August 2016 and still in force. It is worth knowing the number exists, because the thing it says is easy to describe wrongly in either direction.
It has two substantive sections. Nationally Covered Indications reads N/A. Nationally Non-Covered Indications also reads N/A. CMS looked at the evidence, decided no national determination was appropriate, and left the decision to local Medicare Administrative Contractors on a case-by-case basis.
So there is no national rule requiring your contractor to cover this, and there is no national rule permitting it to refuse on national grounds. If a denial tells you Medicare does not cover this nationally, it is describing the absence of a rule as though it were a rule. NCD 140.9 is the citation that says otherwise, and it is short enough to quote in full in an appeal.
Common questions
- Is gender-affirming surgery excluded from Medicare?
- No. NCD 140.9 lists no nationally non-covered indications, so there is no national exclusion. It also lists no nationally covered indications, so there is no national approval. Regional contractors decide case by case.
- Do the December 2025 proposed rules affect me?
- Those proposals target care for minors, not adult Medicare beneficiaries. They signal direction rather than changing adult coverage.
Better covered elsewhere
- Justice in Aging — Medicare advocacy resources
Better than anything on this site for the Medicare appeal ladder specifically. Written for older adults on limited incomes, which is their remit — if you are on Medicare through disability rather than age, the appeal mechanics still apply to you but the framing around them will not sound like it is about you.
Where to go next
Sources for the legal points on this page
- Medicare sets no national criteria — and no national exclusion either
Federal — Medicare · effective NCD 140.9 effective 2016-08-30, still in force
NCD 140.9, Gender Dysphoria and Gender Reassignment Surgery (CMS Pub. 100-3), effective 2016-08-30, no end date; Transmittal 194 / CR9981
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06
Also on this page, without a citation yet
- The Advance Beneficiary Notice validity rules and the Medicare Advantage auto-forward requirement. Both are described here from general knowledge of how the programs work; NEITHER was read from the regulation, unlike the four appeal deadlines above, which were. Confirm with 1-800-MEDICARE or your State Health Insurance Assistance Program before relying on either in a filing.
These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.